Benjamin LZ Shou
Resident in Cardiothoracic Surgery - Thoracic Surgery
Affiliate, Department Funds
Bio
Benjamin Shou is a resident in the integrated cardiothoracic surgery program. He attended medical school at Johns Hopkins and completed his undergraduate degree at University of California, Los Angeles, in Molecular, Cell, and Developmental Biology with a concentration in Computational Biology. His academic interests include adult cardiac surgery, imaging, and artificial intelligence in healthcare.
Clinical Focus
- Residency
- Cardiac Surgery
- Thoracic Surgery
Professional Education
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BS, University of California, Los Angeles, Molecular, Cell, and Developmental Biology (2019)
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MD, Johns Hopkins University School of Medicine (2024)
https://orcid.org/0000-0003-2825-3301All Publications
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Pick Your Perfusion: National Outcomes of Normothermic Regional Perfusion versus Direct Procurement and Perfusion in Donation After Circulatory Death Cardiac Transplants.
The Journal of thoracic and cardiovascular surgery
2026
Abstract
Donation after circulatory death (DCD) cardiac transplantation has substantially expanded the donor pool; however, the optimal procurement strategy - direct procurement and perfusion (DPP) or normothermic regional perfusion (NRP) - remains actively debated. We compared contemporary national outcomes of NRP versus DPP using the United Network for Organ Sharing (UNOS) registry.We analyzed first-time, isolated adult DCD heart transplants performed in the United States between January 1, 2019, and March 31, 2026, using the UNOS Standard Transplant Analysis and Research database. DPP and NRP were defined as a death-to-cross-clamp interval ≤30 and >30 minutes, respectively. Primary outcomes were 1-month, 1-year, and 3-year all-cause mortality. One-to-one propensity score matching (PSM) was performed to compare differences in outcomes between DPP and NRP.The analytic cohort comprised 2,831 DCD heart transplant recipients: 1,737 (61.4%) DPP and 1,094 (38.6%) NRP. DCD comprised 24.6% of all adult heart transplants performed in the United States. After propensity score matching, 939 DPP-NRP pairs were identified. In the matched cohort, survival was lower after DPP than after NRP at 1-month (95.8% vs 97.9%; p=0.01), one year (90% vs 92%, p=0.05), and three years (83.5% vs 86.9%, p=0.04). One year survival was similar on those surviving the first month (94.0% for both groups), as was three year survival conditional on surviving one year (92.7% vs 94.4%, p=0.52).NRP was associated with a modest short-term perioperative survival benefit compared to DPP. Among recipients who survived the first month, one and three year survival was equivalent.
View details for DOI 10.1016/j.jtcvs.2026.08.001
View details for PubMedID 42595217
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Modified Thoracoabdominal Approach for the Repair of Massive Diaphragmatic Hernias.
Annals of thoracic surgery short reports
2026; 4 (2): 471-475
Abstract
Various approaches to treat large diaphragmatic hernias in adults are available depending on the extent of herniation, patient stability, and surgeon experience. We present a 2-case series of massive diaphragmatic hernia repairs using a modified thoracoabdominal technique whereby a stabilizing myocutaneous bridge is left between the thoracotomy and laparotomy incisions. This technique maintains excellent exposure, may be accomplished for either right- or left-sided hernias, and spares a portion of unaffected diaphragm.
View details for DOI 10.1016/j.atssr.2025.12.008
View details for PubMedID 42267034
View details for PubMedCentralID PMC13245284
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Re-evaluating the association between thrombocytopenia and bleeding in extracorporeal membrane oxygenation (ECMO)
PERFUSION-UK
2026; 41 (4): 392-400
Abstract
ObjectivesThe platelet trigger at which to transfuse platelets to prevent bleeding complications in patients supported with extracorporeal membrane oxygenation (ECMO) is unclear. We aimed to elucidate the association between platelet count and bleeding sequelae in this patient population.MethodsWe conducted a single-center retrospective study of all adult patients who received ECMO support from 2017 to 2022. Patients were stratified into two groups: "non-thrombocytopenic" (>30 × 103 cells /μL) versus "thrombocytopenic" (≤30 × 103 cells /μL). Multivariable logistic regression was used to determine the association between thrombocytopenia and bleeding complications; covariates were selected a priori. A post-hoc analysis investigating platelet transfusion status and nadir platelet count as an ordinal variable was also performed.ResultsOf 291 VV- and VA-ECMO patients, 69 (24%) were categorized as "thrombocytopenic" and 144 (50%) experienced at least one major bleeding event. Compared to "non-thrombocytopenic" patients, "thrombocytopenic" patients were more likely to be male (p = 0.049), to require veno-arterial central canulation (p < 0.001), and to have been on dialysis (p < 0.001). Confounded by a 72% prophylactic transfusion rate, "Thrombocytopenia" was not associated with an increased risk of major bleeding (aOR: 0.59 [95% CI: 0.31-1.10]). However, in patients with a nadir platelet count between 31 and 50 × 103 cells/μL, the 63% with a prophylactic platelet transfusion had a significant reduction in major bleeding complications (p = 0.003).ConclusionsOur findings suggest that a platelet transfusion trigger of ≤50 × 103 cells/μL is of benefit for prophylaxis against bleeding during ECMO support.
View details for DOI 10.1177/02676591251364481
View details for Web of Science ID 001541489800001
View details for PubMedID 40737699
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Pick Your Perfusion: National Outcomes of Normothermic Regional Perfusion versus Direct Procurement and Perfusion in Donation After Circulatory Death Cardiac Transplants
MOSBY-ELSEVIER. 2026: S7-S8
View details for DOI 10.1016/j.jtcvs.2026.03.075
View details for Web of Science ID 001765305100013
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High-Granularity Machine Learning Prediction of Acute Brain Injury in Patients Receiving Venoarterial Extracorporeal Membrane Oxygenation
ASAIO JOURNAL
2025; 71 (12): 1013-1022
Abstract
Acute brain injury (ABI) is prevalent among patients undergoing venoarterial extracorporeal membrane oxygenation (VA-ECMO) and significantly impact recovery. Early prediction of ABI could enable timely interventions to prevent adverse outcomes, but existing predictive methods remain suboptimal. This study aimed to enhance ABI prediction using machine learning (ML) models and high-temporal-resolution granular data. We retrospectively analyzed 355 VA-ECMO patients treated at Johns Hopkins Hospital (JHH) from 2016 to 2024, collecting over 3 million data points from the JHH Research Electronic Data Capture (REDCap) database, with an average of 80,000 data points per patient. Acute brain injury was defined as ischemic stroke, intracranial hemorrhage, hypoxic-ischemic brain injury, or seizure. Four ML models were used: Random Forest, Categorical Boosting, Adaptive Boosting, and Extreme Gradient Boosting. Among 355 patients (median age 59 years, 56.9% male), 13.5% developed ABI. The models achieved an optimal area under the receiver operating characteristic curve (AUROC) of 0.79, accuracy of 87%, sensitivity of 53%, specificity of 99%, and precision-recall (PR)-AUC of 0.47. Key predictors included high minimum values of systolic blood pressure and variability in on-ECMO pulse pressure. High-resolution granular data enhanced ML performance for ABI prediction. Future efforts should focus on integrating continuous data platforms to enable real-time monitoring and personalized care, optimizing patient outcomes.
View details for DOI 10.1097/MAT.0000000000002449
View details for Web of Science ID 001629819700009
View details for PubMedID 40310019
View details for PubMedCentralID PMC12354110
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Ross after David: Management of the fused plane between the prior reimplantation valve-sparing aortic root replacement and the pulmonary autograft
JTCVS TECHNIQUES
2025; 34: 84-87
View details for DOI 10.1016/j.xjtc.2025.08.017
View details for Web of Science ID 001630141800001
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Ross after David: Management of the fused plane between the prior reimplantation valve-sparing aortic root replacement and the pulmonary autograft.
JTCVS techniques
2025; 34: 84-87
View details for DOI 10.1016/j.xjtc.2025.08.017
View details for PubMedID 41368402
View details for PubMedCentralID PMC12683042
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Ex vivo optimization of a bicuspid pulmonary valve using the resequenced composite autograft Ross technique.
JTCVS techniques
2025; 33: 75-78
View details for DOI 10.1016/j.xjtc.2025.07.005
View details for PubMedID 41112433
View details for PubMedCentralID PMC12529671
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Ex vivo optimization of a bicuspid pulmonary valve using the resequenced composite autograft Ross technique
JTCVS TECHNIQUES
2025; 33: 75-78
View details for DOI 10.1016/j.xjtc.2025.07.005
View details for Web of Science ID 001588856200015
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Enhancing Survival Prediction After Venoarterial Extracorporeal Membrane Oxygenation Using Machine Learning.
ASAIO journal (American Society for Artificial Internal Organs : 1992)
2025
Abstract
In-hospital mortality after venoarterial extracorporeal membrane oxygenation (VA-ECMO) remains high. This study compared the performance of the Survival after Venoarterial ECMO (SAVE) score with machine learning (ML) models incorporating rich electronic medical record data to evaluate survival for patients on VA-ECMO support. We retrospectively reviewed adults undergoing VA-ECMO (2016-2022) at a single tertiary care center. The CatBoost algorithm was trained using leave-one-out cross-validation (LOOCV) on 74 extracted vital signs, laboratory values, and ventilator settings. Shapley Additive Explanations (SHAP) was used to identify key predictive features for logistic regression. Overall, 194 VA-ECMO patients (median age = 58 years, 36.6% female) were included, with 133 (69%) experiencing mortality. The SAVE score was compared to two predictive models: a pre-ECMO model (≤ 24 hours before cannulation) and an on-ECMO model (including up to the first 48 hours of ECMO). The LOOCV area under the receiver-operator characteristics curves (AUC) for the SAVE score, pre-ECMO, and on-ECMO models was 0.73, 0.77, and 0.83, respectively. Logistic regressions using ML-identified variables showed stepwise AUC improvements: 0.82 (pre-ECMO), 0.86 (on-ECMO), and 0.89 (combined). A novel, interpretable ML model predicted survival for VA-ECMO patients with accuracy comparable to the SAVE score. Incorporating on-ECMO variables significantly increased predictive performance and revealed novel variables associated with survival.
View details for DOI 10.1097/MAT.0000000000002475
View details for PubMedID 40454690
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Concurrent aortic valve replacement and splenectomy for Q-fever endocarditis with massive splenomegaly and pancytopenia.
JTCVS techniques
2025; 30: 73-76
View details for DOI 10.1016/j.xjtc.2025.01.021
View details for PubMedID 40242106
View details for PubMedCentralID PMC11998301
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A Novel, Interpretable Machine Learning Model to Predict Neurological Outcomes Following Venoarterial Extracorporeal Membrane Oxygenation.
Neurocritical care
2025
Abstract
BACKGROUND: We used machine learning models incorporating rich electronic medical record (EMR) data to predict neurological outcomes after venoarterial extracorporeal membrane oxygenation (VA-ECMO).METHODS: This was a retrospective review of adult (≥18years) patients undergoing VA-ECMO between 6/2016 and 4/2022 at a single center. The primary outcome was good neurological outcome, defined as a modified Rankin Scale score of 0 to 3, evaluated at hospital discharge. We extracted every measurement of 74 vital and laboratory values, as well as circuit and ventilator settings, from 24h before cannulation through the entire duration of ECMO. An XGBoost model with Shapley Additive Explanations was developed and evaluated with leave-one-out cross-validation.RESULTS: Overall, 194 patients undergoing VA-ECMO (median age 58years, 63% male) were included. We extracted more than 14 million individual data points from the EMR. Of 194 patients, 39 patients (20%) had good neurological outcomes. Three models were generated: model A, which contained only pre-ECMO data; model B, which added data from the first 48h of ECMO; and model C, which included data from the entire ECMO run. The leave-one-out cross-validation area under the receiver operator characteristics curves for models A, B, and C were 0.72, 0.81, and 0.90, respectively. The inclusion of on-ECMO physiologic, laboratory, and circuit data greatly improved model performance. Both modifiable and nonmodifiable variables, such as lower body mass index, lower age, higher mean arterial pressure, and higher hemoglobin, were associated with good neurological outcome.CONCLUSIONS: An interpretable machine learning model from EMR-extracted data was able to predict neurological outcomes for patients undergoing VA-ECMO with excellent accuracy.
View details for DOI 10.1007/s12028-025-02233-0
View details for PubMedID 40148658
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Long-term outcomes of heparin-induced thrombocytopenia after cardiac surgery
JTCVS OPEN
2025; 23: 190-198
Abstract
Heparin-induced thrombocytopenia (HIT) after cardiac surgery may lead to greater morbidity and mortality than predicted preoperatively. The aim of this study is to assess long-term outcomes of patients surviving HIT after cardiac surgery.Single-institution, retrospective study of adult patients who underwent cardiac surgery between 2011 and 2023 and developed HIT postoperatively. The institutional Society of Thoracic Surgeons database and electronic medical record were integrated with longitudinal data from phone questionnaires. HIT was defined by combined clinical (4Ts score) and serologic manifestations: a platelet decrease >50% from preoperative baseline, a high optical density positive heparin-PF4 antibody test, and a positive serotonin release assay.We identified 88 of 11,658 patients (0.8%) with HIT after cardiac surgery. The majority were male (74%), white (73.8%), and with a mean age of 65.6 ± 11.6 years. Seventy-seven (87.5%) survived to discharge, had a 4Ts score of 5 [4-6], and 58 (75.3%) were discharged on oral anticoagulation, with only 22 (28.6%) receiving treatment for the past 3 months, for a median of 1.3 [0.8-4.5] years. Median length of stay was 24 [17-35] days and length of follow-up was 4.6 [0.3-12] years. Readmission occurred in 70.1% (n = 54) of patients, with an average of 3 [1-6] readmissions/patient. Causes of death during follow-up included cardiac (n = 7, 24.1%), infectious (n = 6, 20.7%), or neurologic events (n = 5, 17.3). Ten-year survival probability was 48%.Patients who develop HIT after cardiac surgery have an overall poor prognosis even after hospital discharge. In addition to prolonged hospitalization, patients experience further complications leading to frequent early readmissions and elevated mortality in the long-term.
View details for DOI 10.1016/j.xjon.2024.10.029
View details for Web of Science ID 001432619000001
View details for PubMedID 40061541
View details for PubMedCentralID PMC11883693
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Pulse Pressure and Acute Brain Injury in Venoarterial Extracorporeal Membrane Oxygenation: An Extracorporeal Life Support Organization Registry Analysis
ASAIO JOURNAL
2025; 71 (2): 99-108
Abstract
Low pulse pressure (PP) in venoarterial-extracorporeal membrane oxygenation (VA-ECMO) is a marker of cardiac dysfunction and has been associated with acute brain injury (ABI) as continuous-flow centrifugal pump may lead to endothelial dysregulation. We retrospectively analyzed adults (≥18 years) receiving "peripheral" VA-ECMO for cardiogenic shock in the Extracorporeal Life Support Organization Registry (January 2018-July 2023). Acute brain injury (our primary outcome) included central nervous system (CNS) ischemia, intracranial hemorrhage, brain death, and seizures. Multivariable logistic regressions were performed to examine whether PP ≤10 mm Hg was associated with ABI. Of 9,807 peripheral VA-ECMO patients (median age = 57.4 years, 67% = male), 8,294 (85%) had PP >10 mm Hg versus 1,513 (15%) had PP ≤10 mm Hg. Patients with PP ≤10 mm Hg experienced ABI more frequently versus PP >10 mm Hg (15% versus 11%, p < 0.001). After adjustment, PP ≤10 mm Hg was independently associated with ABI (adjusted odds ratio [aOR] = 1.25, 95% confidence interval [CI] = 1.06-1.48, p = 0.01). Central nervous system ischemia and brain death were more common in patients with PP ≤10 versus PP >10 mm Hg (8% versus 6%, p = 0.008; 3% versus 1%, p < 0.001). Pulse pressure ≤10 mm Hg was associated with CNS ischemia (aOR = 1.26, 95% CI = 1.02-1.56, p = 0.03) but not intracranial hemorrhage (aOR = 1.14, 95% CI = 0.85-1.54, p = 0.38). Early low PP (≤10 mm Hg) at 24 hours of ECMO support was associated with ABI, particularly CNS ischemia, in peripheral VA-ECMO patients.
View details for DOI 10.1097/MAT.0000000000002294
View details for Web of Science ID 001412638800014
View details for PubMedID 39178166
View details for PubMedCentralID PMC11781983
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Advancements in Computed Tomography Analysis for Thoracic Aortic Surgery: The Expanding Role of Automation
HEART SURGERY FORUM
2025; 28 (8): E644-E655
View details for DOI 10.59958/hsf.8381
View details for Web of Science ID 001569166300008
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Bigger pies, bigger slices: Increased hospitalization costs for lung transplantation recipients in the non-donation service area allocation era
MOSBY-ELSEVIER. 2025: 316-326.e8
Abstract
On November 24, 2017, lung transplant allocation switched from donation service area to a 250-nautical mile radius policy to improve equity in access to lung transplantation. Given the growing consideration of healthcare costs, we evaluated changes in hospitalization costs after this policy change.Lung transplant hospitalizations were identified within the National Inpatient Sample from 2005 to 2020. Recipients were categorized as donation service area era (August 2015 to October 2017) or non-donation service area era (December 2017 to February 2020). Median total hospitalization costs (inflation adjusted) were compared by era nationally and regionally. Multivariable generalized linear regression was performed to determine if the removal of the donation service area was associated with total hospitalization costs. The model was adjusted for recipient demographics, Charlson Comorbidity Index, hospitalization region, transplant type (single, double), and use of extracorporeal membrane oxygenation, ex vivo lung perfusion, and mechanical ventilation.We analyzed 12,985 lung transplant recipients (median age of 61 years, 66% were male): 7070 in the donation service area era and 5915 in the non-donation service area era. Demographics were not different between recipients in both eras. Non-donation service area era recipients had greater extracorporeal membrane oxygenation use, mechanical ventilation (<24 hours), and longer length of stay than donation service area era recipients. Median total hospitalization costs for non-donation service area versus donation service area era recipients increased by $24,198 ($157,964 vs $182,162, percentage change = 15.32%, P < .001). Median costs increased in East North Central ($42,281) and Mountain ($35,521) regions (both P < .01). After adjustment, median costs for non-donation service area versus donation service area era recipients still increased ($19,168, 95% CI, 145-38,191, P = .048).Hospitalization costs for lung transplant hospitalizations have increased from 2015 to 2020. The transition from donation service area-based allocation to the non-donation service area system may have contributed to this increase after 2017 by increasing access to transplant for sicker recipients.
View details for DOI 10.1016/j.jtcvs.2024.01.045
View details for Web of Science ID 001392513400001
View details for PubMedID 38678473
View details for PubMedCentralID PMC11513401
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Changes in Donor Utilization and Outcomes for Patients Bridged With Durable Left Ventricular Assist Device
ASAIO JOURNAL
2024; 70 (11): 964-970
Abstract
We studied the impact of the 2018 heart allocation policy change on donor characteristics and posttransplant outcomes of left ventricular assist device (LVAD)-bridged heart transplant (HT) recipients. Left ventricular assist device-bridged adult HT recipients from October 2014 to October 2022 in the United Network for Organ Sharing database were categorized into old allocation policy (OAP) and new allocation policy (NAP) cohorts. Baseline characteristics, posttransplant outcomes, and subgroup analyses of unstable and stable LVAD-bridged recipients were assessed. The study included 7,384 HT recipients; 4,345 (58.8%) were transplanted in the OAP era and 3,039 (41.2%) in the NAP era. Old allocation policy recipients were most frequently status 1A at transplantation (71.1%), whereas NAP recipients were most frequently status 3 (40.0%), and status 4 (31.9%). Median donor sequence number (DSN) was higher in the NAP versus OAP era (9 vs. 3, p < 0.001). On multivariable analysis, NAP recipients had 20% higher 1 year mortality compared to OAP (adjusted hazard ratio [aHR] = 1.20 [95% confidence interval {CI}: 1.04-1.40], p = 0.01). Status 1 or 2 recipients had 28% higher 1 year mortality compared to status 1A (aHR = 1.28 [95% CI: 1.01-1.63], p = 0.04). Status 1 and 2 LVAD-supported recipients had higher mortality following the 2018 allocation change, indicating the need for closer surveillance of LVAD-bridged patients who may decompensate on the waitlist.
View details for DOI 10.1097/MAT.0000000000002228
View details for Web of Science ID 001348606100009
View details for PubMedID 38728740
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Using machine learning to predict neurologic injury in venovenous extracorporeal membrane oxygenation recipients: An ELSO Registry analysis
JTCVS OPEN
2024; 21: 140-167
Abstract
Venovenous extracorporeal membrane oxygenation (VV-ECMO) is associated with acute brain injury (ABI), including central nervous system (CNS) ischemia (defined as ischemic stroke or hypoxic-ischemic brain injury [HIBI]) and intracranial hemorrhage (ICH). Data on prediction models for neurologic outcomes in VV-ECMO are limited.We analyzed adult (age ≥18 years) VV-ECMO patients in the Extracorporeal Life Support Organization (ELSO) Registry (2009-2021) from 676 centers. ABI was defined as CNS ischemia, ICH, brain death, and seizures. Data on 67 variables were extracted, including clinical characteristics and pre-ECMO/on-ECMO variables. Random forest, CatBoost, LightGBM, and XGBoost machine learning (ML) algorithms (10-fold leave-one-out cross-validation) were used to predict ABI. Feature importance scores were used to pinpoint the most important variables for predicting ABI.Of 37,473 VV-ECMO patients (median age, 48.1 years; 63% male), 2644 (7.1%) experienced ABI, including 610 (2%) with CNS ischemia and 1591 (4%) with ICH. The areas under the receiver operating characteristic curve for predicting ABI, CNS ischemia, and ICH were 0.70, 0.68, and 0.70, respectively. The accuracy, positive predictive value, and negative predictive value for ABI were 85%, 19%, and 95%, respectively. ML identified higher center volume, pre-ECMO cardiac arrest, higher ECMO pump flow, and elevated on-ECMO serum lactate level as the most important risk factors for ABI and its subtypes.This is the largest study of VV-ECMO patients to use ML to predict ABI reported to date. Performance was suboptimal, likely due to lack of standardization of neuromonitoring/imaging protocols and data granularity in the ELSO Registry. Standardized neurologic monitoring and imaging are needed across ELSO centers to detect the true prevalence of ABI.
View details for DOI 10.1016/j.xjon.2024.06.013
View details for Web of Science ID 001350739900001
View details for PubMedID 39534333
View details for PubMedCentralID PMC11551311
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Discussion to: Intraoperative blood products, fluid administration, and persistent hypothermia on bleeding leading to reexploration after cardiac surgery
JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY
2024; 168 (3): 885-887
View details for DOI 10.1016/j.jtcvs.2023.11.002
View details for Web of Science ID 001316266300001
View details for PubMedID 38032555
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Acute brain injury risk prediction models in venoarterial extracorporeal membrane oxygenation patients with tree-based machine learning: An Extracorporeal Life Support Organization Registry analysis
JTCVS OPEN
2024; 20: 64-88
Abstract
We aimed to determine if machine learning can predict acute brain injury and to identify modifiable risk factors for acute brain injury in patients receiving venoarterial extracorporeal membrane oxygenation.We included adults (age ≥18 years) receiving venoarterial extracorporeal membrane oxygenation or extracorporeal cardiopulmonary resuscitation in the Extracorporeal Life Support Organization Registry (2009-2021). Our primary outcome was acute brain injury: central nervous system ischemia, intracranial hemorrhage, brain death, and seizures. We used Random Forest, CatBoost, LightGBM, and XGBoost machine learning algorithms (10-fold leave-1-out cross-validation) to predict and identify features most important for acute brain injury. We extracted 65 total features: demographics, pre-extracorporeal membrane oxygenation/on-extracorporeal membrane oxygenation laboratory values, and pre-extracorporeal membrane oxygenation/on-extracorporeal membrane oxygenation settings.Of 35,855 patients receiving venoarterial extracorporeal membrane oxygenation (nonextracorporeal cardiopulmonary resuscitation) (median age of 57.8 years, 66% were male), 7.7% (n = 2769) experienced acute brain injury. In venoarterial extracorporeal membrane oxygenation (nonextracorporeal cardiopulmonary resuscitation), the area under the receiver operator characteristic curves to predict acute brain injury, central nervous system ischemia, and intracranial hemorrhage were 0.67, 0.67, and 0.62, respectively. The true-positive, true-negative, false-positive, false-negative, positive, and negative predictive values were 33%, 88%, 12%, 67%, 18%, and 94%, respectively, for acute brain injury. Longer extracorporeal membrane oxygenation duration, higher 24-hour extracorporeal membrane oxygenation pump flow, and higher on-extracorporeal membrane oxygenation partial pressure of oxygen were associated with acute brain injury. Of 10,775 patients receiving extracorporeal cardiopulmonary resuscitation (median age of 57.1 years, 68% were male), 16.5% (n = 1787) experienced acute brain injury. The area under the receiver operator characteristic curves for acute brain injury, central nervous system ischemia, and intracranial hemorrhage were 0.72, 0.73, and 0.69, respectively. Longer extracorporeal membrane oxygenation duration, older age, and higher 24-hour extracorporeal membrane oxygenation pump flow were associated with acute brain injury.In the largest study predicting neurological complications with machine learning in extracorporeal membrane oxygenation, longer extracorporeal membrane oxygenation duration and higher 24-hour pump flow were associated with acute brain injury in nonextracorporeal cardiopulmonary resuscitation and extracorporeal cardiopulmonary resuscitation venoarterial extracorporeal membrane oxygenation.
View details for DOI 10.1016/j.xjon.2024.06.001
View details for Web of Science ID 001314431400001
View details for PubMedID 39296456
View details for PubMedCentralID PMC11405982
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Impact of Extracorporeal Membrane Oxygenation Bridging Duration on Lung Transplant Outcomes
ANNALS OF THORACIC SURGERY
2024; 118 (2): 496-503
Abstract
We sought to characterize the association between venovenous extracorporeal membrane oxygenation (VV-ECMO) bridging duration and outcomes in patients listed for lung transplantation.A retrospective observational study was conducted using the Organ Procurement and Transplantation Network (OPTN) database to identify adults (aged ≥18 years) who were listed for lung transplantation between 2016 and 2020 and were bridged with VV-ECMO. Patients were then stratified into groups, determined by risk inflection points, depending on the amount of time spent on pretransplant ECMO: group 1 (≤5 days), group 2 (6-10 days), group 3 (11-20 days), and group 4 (>20 days). Waiting list survival between groups was analyzed using Fine-Gray competing risk models. Posttransplant survival was compared using Cox regression.Of 566 eligible VV-ECMO bridge-to-lung-transplant patients (median age, 54 years, 49% men), 174 (31%), 124 (22%), 130 (23%), and 138 (24%) were categorized as groups 1, 2, 3, and 4, respectively. Overall, median duration of VV-ECMO was 10 days (interquartile range, 1-211 days), and 178 patients (31%) died on the waiting list. In the Fine-Gray model, compared with group 1, patients bridged with longer ECMO durations in group 2 (subdistribution hazard ratio [SHR], 2.95; 95% CI, 1.63-5.35), group 3 (SHR, 3.96; 95% CI, 2.36-6.63), and group 4 (SHR, 4.33; 95% CI, 2.59-7.22, all P < .001) were more likely to die on the waiting list. Of 388 patients receiving a transplant, pretransplant ECMO duration was not associated with 1-year survival in Cox regression.Prolonged duration of ECMO bridging was associated with worse waiting list mortality but did not impact survival after lung transplant. Prioritization of very early transplantation may improve waiting list outcomes in this population.
View details for DOI 10.1016/j.athoracsur.2024.04.021
View details for Web of Science ID 001278300600001
View details for PubMedID 38740080
View details for PubMedCentralID PMC11284668
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Impact of Heart Failure Etiology on Waitlist Mortality in Heart Transplant Candidates Supported With Extracorporeal Membrane Oxygenation
CLINICAL TRANSPLANTATION
2024; 38 (8): e15421
Abstract
Extracorporeal membrane oxygenation (ECMO) has gained traction as a bridge to heart transplantation (HT) but remains associated with increased waitlist mortality. This study explores whether this risk is modified by underlying heart failure (HF) etiology.Using the Organ Procurement and Transplantation Network registry, we conducted a retrospective review of first-time adult HT candidates from 2018 through 2022. Patients were categorized as "ECMO", if ECMO was utilized during the waitlisting period, or "No ECMO" otherwise. Patients were then stratified according to the following HF etiology: ischemic cardiomyopathy (CMP), dilated nonischemic CMP, restrictive CMP, hypertrophic CMP, and congenital heart disease (CHD). After baseline comparisons, waitlist mortality was characterized for ECMO and HF etiology using the Fine-Gray regression.A total of 16 143 patients were identified of whom 7.0% (n = 1063) were bridged with ECMO. Compared to No ECMO patients, ECMO patients had shorter waitlist durations (46.3 vs. 185.0 days, p < 0.01) and were more likely to undergo transplantation (75.3% vs. 70.3%, p < 0.01). Outcomes analysis revealed that ECMO was associated with increased mortality risk (subdistribution hazard ratio [SHR]: 3.42, p < 0.01), a risk that persisted in all subgroups and was notably high in CHD (SHR: 4.83, p < 0.01) and hypertrophic CMP (SHR: 9.78, p < 0.01). HF etiology comparison within ECMO patients revealed increased mortality risk with CHD (SHR: 3.22, p < 0.01). Within No ECMO patients, hypertrophic CMP patients had lower mortality risk (SHR: 0.64, p = 0.03).The increased waitlist mortality risk with ECMO persisted after stratification by HF etiology. These findings can help decision-making surrounding candidacy for cannulation and prognostic evaluation.
View details for DOI 10.1111/ctr.15421
View details for Web of Science ID 001291179400001
View details for PubMedID 39140404
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National utilization, trends, and lung transplant outcomes of static versus portable ex vivo lung perfusion platforms
JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY
2024; 168 (2): 431-439
Abstract
This study compared utilization and outcomes of the 2 widely utilized ex vivo lung perfusion (EVLP) platforms in the United States: a static platform and a portable platform.Adult (age 18 years or older) bilateral lung-only transplants utilizing EVLP between February 28, 2018, and December 31, 2022, in the United Network for Organ Sharing database were included. Predischarge acute rejection, intubation at 72 hours posttransplant, extracorporeal membrane oxygenation at 72 hours posttransplant, primary graft dysfunction grade 3 at 72 hours posttransplant, 30-day mortality, and 1-year mortality were evaluated using multivariable regressions.Overall, 607 (6.3%) lung transplants during the study period used EVLP (51.2% static, 48.8% portable). Static EVLP was primarily utilized in the eastern United States, whereas portable EVLP was primarily utilized in the western United States. Static EVLP donors were more likely to be donation after circulatory death (33.4% vs 26.0%; P = .005), have a >20 pack-year smoking history (13.5% vs 6.5%; P = .005), and be extended criteria donors (92.3% vs 85.0%; P = .013), whereas portable EVLP donors were more likely to be older than age 55 years (14.2% vs 8.0%; P = .02). Transplants utilizing the static and portable platforms had similar risk of acute rejection, intubation at 72 hours, extracorporeal membrane oxygenation at 72 hours, primary graft dysfunction grade 3 at 72 hours, and posttransplant mortality at 30 days and 1 year (all P values > .05).The static and portable platforms had significant differences in donor characteristics and geographic distributions of utilization. Despite this, posttransplant survival was similar between the 2 EVLP platforms.
View details for DOI 10.1016/j.jtcvs.2023.12.015
View details for Web of Science ID 001272660800001
View details for PubMedID 38141853
View details for PubMedCentralID PMC11192856
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Machine Learning from Veno-Venous Extracorporeal Membrane Oxygenation Identifies Factors Associated with Neurological Outcomes
LUNG
2024; 202 (4): 465-470
Abstract
Neurological complications are common in patients receiving veno-venous extracorporeal membrane oxygenation (VV-ECMO) support. We used machine learning (ML) algorithms to identify predictors for neurological outcomes for these patients.All demographic, clinical, and circuit-related variables were extracted for adults with VV-ECMO support at a tertiary care center from 2016 to 2022. The primary outcome was good neurological outcome (GNO) at discharge defined as a modified Rankin Scale of 0-3.Of 99 total VV-ECMO patients (median age = 48 years; 65% male), 37% had a GNO. The best performing ML model achieved an area under the receiver operating characteristic curve of 0.87. Feature importance analysis identified down-trending gas/sweep/blender flow, FiO2, and pump speed as the most salient features for predicting GNO.Utilizing pre- as well as post-initiation variables, ML identified on-ECMO physiologic and pulmonary conditions that best predicted neurological outcomes.
View details for DOI 10.1007/s00408-024-00708-z
View details for Web of Science ID 001235459300001
View details for PubMedID 38814448
View details for PubMedCentralID PMC11417431
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Extracorporeal Membrane Oxygenation Physiological Factors Influence Pulse Oximetry and Arterial Oxygen Saturation Discrepancies
ANNALS OF THORACIC SURGERY
2024; 117 (6): 1221-1228
Abstract
Cannulation strategy, vasopressors, and hemolysis are important physiological factors that influence hemodynamics in extracorporeal membrane oxygenation (ECMO). We hypothesized these factors influence the discrepancy between oxygen saturation measured by pulse oximetry (Spo2) and arterial blood gas (Sao2) in patients on ECMO.We retrospectively analyzed adults (aged ≥18 years) on venoarterial or venovenous ECMO at a tertiary academic ECMO center. Spo2-Sao2 pairs with oxygen saturation ≥70% and measured within 10 minutes were included. Occult hypoxemia was defined as Sao2 ≤88% with a time-matched Spo2 ≥92%. Adjusted linear mixed-effects modeling was used to assess the Spo2-Sao2 discrepancy with preselected demographics and time-matched laboratory variables. Vasopressor use was quantified by vasopressor dose equivalences.Of 139 venoarterial-ECMO and 88 venovenous-ECMO patients, we examined 20,053 Spo2-Sao2 pairs. The Spo2-Sao2 discrepancy was greater in venovenous-ECMO (1.15%) vs venoarterial-ECMO (-0.35%, P < .001). Overall, 81 patients (35%) experienced occult hypoxemia during ECMO. Occult hypoxemia was more common in venovenous-ECMO (65%) than in venoarterial-ECMO (17%, P < .001). In linear mixed-effects modeling, Spo2 underestimated Sao2 by 9.48% in central vs peripheral venoarterial-ECMO (95% CI, -17.1% to -1.79%; P = .02). Higher vasopressor dose equivalences significantly worsened the Spo2-Sao2 discrepancy (P < .001). In linear mixed-effects modeling, Spo2 overestimated Sao2 by 25.43% in single lumen-cannulated vs double lumen-cannulated venovenous-ECMO (95% CI, 5.27%-45.6%; P = .03). Higher vasopressor dose equivalences and lactate dehydrogenase levels significantly worsened the Spo2-Sao2 discrepancy (P < .001).Venovenous-ECMO patients are at higher risk for occult hypoxemia compared with venoarterial-ECMO. A higher vasopressor requirement and different cannulation strategies (central venoarterial-ECMO; single-lumen venovenous-ECMO) were significant factors for clinically significant Spo2-Sao2 discrepancy in both ECMO modes.
View details for DOI 10.1016/j.athoracsur.2023.09.019
View details for Web of Science ID 001292539100001
View details for PubMedID 37748529
View details for PubMedCentralID PMC10959762
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The impact of local programmatic decisions on outcomes in transplant-listed adults with congenital heart disease.
Journal of cardiac failure
2024
Abstract
BACKGROUND: We investigated variables impacting waitlist time and negative waitlist outcomes in adult congenital heart disease (ACHD) orthotopic heart transplant (OHT) candidates following the 2018 allocation change.METHODS: Adult OHT candidates listed between 10/18/2018-12/31/2022 in the United Network for Organ Sharing database were categorized as ACHD vs. non-ACHD. Waitlist time and time to upgrade for those upgraded into status 1-3 were compared using rank-sum tests. Death/delisting for deterioration was assessed using Fine-Gray sub-distribution hazard ratios (SHRs).RESULTS: Of 15,424 OHT candidates, 589 (3.8%) were ACHD. ACHD vs. non-ACHD candidates had less urgent status at initial listing (4.2% vs. 4.7% listed at status 1; 17.2% vs. 23.7% listed at status 2, p<0.001), but not final listing (5.9% vs. 7.6% final status 1; 35.6% vs. 36.8% final status 2, p<0.001). ACHD vs. non-ACHD candidates upgraded into status 1 (65.0 vs. 30.0 days, p=0.09) and status 2 (113.0 vs. 64.0 days, p=0.003) spent longer on the waitlist. ACHD vs. non-ACHD candidates spent longer waiting for an upgrade into status 1 (51.4 vs. 17.6 days, p=0.027) and status 2 (76.7 vs. 34.7 days, p=0.003). Once upgraded, there was no difference between groups in waitlist time as status 1 (9.7 vs. 5.5 days, p=0.66). ACHD vs. non-ACHD candidates with a final status of 1 (20.0% vs. 8.6%; SHR 2.47 [95%CI=1.19-5.16], p=0.02) and 2 (8.9% vs. 2.3%; SHR 3.59 [95%CI=2.18-5.91], p<0.001) experienced higher death/deterioration.CONCLUSIONS: ACHD candidates have longer waitlist times, lower priority status at initial listing, wait longer for upgrade, and have higher mortality at the same final status as non-ACHD candidates, suggesting that they are being upgraded too late.
View details for DOI 10.1016/j.cardfail.2024.04.001
View details for PubMedID 38616008
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Outcomes of Lung Transplant Candidates Aged ≥ 70 Years During the Lung Allocation Score Era
ANNALS OF THORACIC SURGERY
2024; 117 (4): 725-732
Abstract
With the increasing age of lung transplant candidates, we studied waitlist and posttransplantation outcomes of candidates ≥70 years during the Lung Allocation Score era.Adult lung transplant candidates from 2005 to 2020 in the United Network for Organ Sharing database were included and stratified on the basis of age at listing into 18 to 59 years old, 60 to 69 years old, and ≥70 years old. Baseline characteristics, waitlist outcomes, and posttransplantation outcomes were assessed.A total of 37,623 candidates were included (52.3% aged 18-59 years, 40.6% aged 60-69 years, 7.1% aged ≥70 years). Candidates ≥70 years were more likely than younger candidates to receive a transplant (81.9% vs 72.7% [aged 60-69 years] vs 61.6% [aged 18-59 years]) and less likely to die or to deteriorate on the waitlist within 1 year (9.1% vs 10.1% [aged 60-69 years] vs 12.2% [aged 18-59 years]; P < .001). Donors for older recipients were more likely to be extended criteria (75.7% vs 70.1% [aged 60-69 years] vs 65.7% [aged 18-59 years]; P < .001). Recipients ≥70 years were found to have lower rates of acute rejection (6.7% vs 7.4% [aged 60-69 years] vs 9.2% [aged 18-59 years]; P < .001) and prolonged intubation (21.7% vs 27.4% [aged 60-69 years] vs 34.5% [aged 18-59 years]; P < .001). Recipients aged ≥70 years had increased 1-year (adjusted hazard ratio [aHR], 1.19 [95% CI, 1.06-1.33]; P < .001), 3-year (aHR, 1.28 [95% CI, 1.18-1.39]; P < .001), and 5-year mortality (aHR, 1.29 [95% CI, 1.21-1.38]; P < .001) compared with recipients aged 60 to 69 years.Candidates ≥70 years had favorable waitlist and perioperative outcomes despite increased use of extended criteria donors. Careful selection of candidates and postoperative surveillance may improve posttransplantation survival in this population.
View details for DOI 10.1016/j.athoracsur.2023.04.046
View details for Web of Science ID 001217541800001
View details for PubMedID 37271446
View details for PubMedCentralID PMC10693648
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Outcomes of Recipients Aged 65 Years and Older Bridged to Lung Transplant With Extracorporeal Membrane Oxygenation
ASAIO JOURNAL
2024; 70 (3): 230-238
Abstract
Extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplant (BTT) has been used for critically ill candidates with excellent outcomes, but data on this strategy in older recipients remain limited. We compared outcomes of no BTT, mechanical ventilation (MV)-only BTT, and ECMO BTT in recipients of greater than or equal to 65 years. Lung-only recipients of greater than or equal to 65 years in the United Network for Organ Sharing database between 2008 and 2022 were included and stratified by bridging strategy. Of the 9,936 transplants included, 226 (2.3%) were MV-only BTT and 159 (1.6%) were ECMO BTT. Extracorporeal membrane oxygenation BTT recipients were more likely to have restrictive disease pathology, had higher median lung allocation score, and spent fewer days on the waitlist (all p < 0.001). Compared to no-BTT recipients, ECMO BTT recipients were more likely to be intubated or on ECMO at 72 hours posttransplant and had longer hospital lengths of stay (all p < 0.001). Extracorporeal membrane oxygenation BTT recipients had increased risk of 3 years mortality compared to both no-BTT (adjusted hazard ratio [aHR] = 1.48 [95% confidence interval {CI}: 1.14-1.91], p = 0.003) and MV-only recipients (aHR = 1.50 [95% CI: 1.08-2.07], p = 0.02). Overall, we found that ECMO BTT in older recipients is associated with inferior posttransplant outcomes compared to MV-only or no BTT, but over half of recipients remained alive at 3 years posttransplant.
View details for DOI 10.1097/MAT.0000000000002092
View details for Web of Science ID 001171818000004
View details for PubMedID 37939695
View details for PubMedCentralID PMC10922625
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Early Reexploration for Postoperative Bleeding in Cardiac Surgery Is Beneficial Regardless of Bleeding Site, Even When Undetectable
ANNALS OF THORACIC SURGERY
2024; 117 (2): 484
View details for DOI 10.1016/j.athoracsur.2023.04.038
View details for Web of Science ID 001156513800001
View details for PubMedID 37178859
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Relationship between impaired myocardial blood flow by positron emission tomography and low-attenuation plaque burden and pericoronary adipose tissue attenuation from coronary computed tomography: From the prospective PACIFIC trial
JOURNAL OF NUCLEAR CARDIOLOGY
2023; 30 (4): 1558-1569
View details for DOI 10.1007/s12350-022-03194-z
View details for Web of Science ID 000914382600001
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Trends on Near-Infrared Spectroscopy Associated With Acute Brain Injury in Venoarterial Extracorporeal Membrane Oxygenation
ASAIO JOURNAL
2023; 69 (12): 1083-1089
Abstract
We aimed to determine the association between cerebral regional oxygen saturation (rSO 2 ) trends from cerebral near-infrared spectroscopy (cNIRS) and acute brain injury (ABI) in adult venoarterial extracorporeal membrane oxygenation (VA-ECMO) patients. ABI was defined as intracranial hemorrhage, ischemic stroke, hypoxic ischemic brain injury, or brain death during ECMO. rSO 2 values were collected from left and right cerebral oximetry sensors every hour from ECMO cannulation. Cerebral desaturation was defined as consecutive hours of rSO 2 < 40%. rSO 2 asymmetry was determined by (a) averaging left/right rSO 2 difference over the entire ECMO run; (b) consecutive hours of rSO 2 asymmetry. Sixty-nine VA-ECMO patients (mean age 56 years, 65% male) underwent cNIRS. Eighteen (26%) experienced ABI. When the mean rSO 2 asymmetry was >8% there was significantly increased odds of ABI (aOR = 39.4; 95% CI = 4.1-381.4). Concurrent rSO 2 < 40% and rSO 2 asymmetry >10% for >10 consecutive hours (asymmetric desaturation) was also significantly associated with ABI (aOR = 5.2; 95% CI = 1.2-22.2), but neither criterion alone were. Mean rSO 2 asymmetry>8% exhibited 39% sensitivity and 98% specificity for detecting ABI, with an area under the curve (AUC) of 0.86, and asymmetric desaturation had 33% sensitivity and 88% specificity, with an AUC of 0.72. These trends on NIRS monitoring may help detect ABI in VA-ECMO patients.
View details for DOI 10.1097/MAT.0000000000002032
View details for Web of Science ID 001186852400006
View details for PubMedID 37556554
View details for PubMedCentralID PMC10843160
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Incidence, risk factors, and outcomes of postoperative stroke in combined heart-lung transplantation: A retrospective cohort study of the UNOS registry
CLINICAL TRANSPLANTATION
2024; 38 (1): e15207
Abstract
Stroke is a well-characterized complication of isolated heart and lung transplantation, but has not been described in combined heart-lung transplantation (HLTx). We retrospectively reviewed national U.S. data to describe the incidence, risk factors, and impact of postoperative stroke in HLTx recipients. Of 871 heart-lung recipients between 1994-2022, 35 (4.0%) experienced stroke, and the incidence increased over time, trending toward significance (p-trend = .07). After adjustment, extracorporeal membrane oxygenation (ECMO) (Adjusted odds ratio [aOR] = 2.63, 95%CI = [1.13-6.11]) and pre-transplant implantable defibrillator (aOR = 2.86, 95%CI = [1.20-6.81]) were independent risk factors for stroke. Postoperative stroke is common and is increasing in an era where organ allocation is driven by mechanical circulatory support (MCS) bridging.
View details for DOI 10.1111/ctr.15207
View details for Web of Science ID 001111959500001
View details for PubMedID 38041483
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Epidemiology of ischemic stroke and hemorrhagic stroke in venoarterial extracorporeal membrane oxygenation
CRITICAL CARE
2023; 27 (1): 433
Abstract
While venoarterial extracorporeal membrane oxygenation (V-A ECMO) provides lifesaving support for cardiopulmonary failure, complications may increase mortality, with few studies focusing on ischemic/hemorrhagic stroke. We aimed to determine the trends and associations of stroke incidence and mortality, and their risk factors, including the effects of annual case volumes of ECMO centers.Retrospective analysis was performed on the Extracorporeal Life Support Organization (ELSO) registry, including adult V-A ECMO patients from 534 international centers between 2012 and 2021, excluding extracorporeal cardiopulmonary resuscitation. Temporal trend analyses were performed for stroke incidence and mortality. Univariate testing, multivariable regression, and survival analysis were used to evaluate the associations of stroke, 90-day mortality, and impact of annual center volume.Of 33,041 patients, 20,297 had mortality data, and 12,327 were included in the logistic regression. Between 2012 and 2021, ischemic stroke incidence increased (p < 0.0001), hemorrhagic stroke incidence remained stable, and overall 90-day mortality declined (p < 0.0001). Higher 24-h PaO2 and greater decrease between pre-ECMO PaCO2 and post-cannulation 24-h PaCO2 were associated with greater ischemic stroke incidence, while annual case volume was not. Ischemic/hemorrhagic strokes were associated with increased 90-day mortality (both p < 0.0001), while higher annual case volume was associated with lower 90-day mortality (p = 0.001). Hazard of death was highest in the first several days of V-A ECMO.In V-A ECMO patients between 2012 and 2021, 90-day mortality decreased, while ischemic stroke incidence increased. ELSO centers with higher annual case volumes had lower mortality, but were not associated with ischemic/hemorrhagic stroke incidence. Both ischemic/hemorrhagic strokes were associated with increased mortality.
View details for DOI 10.1186/s13054-023-04707-z
View details for Web of Science ID 001103064800002
View details for PubMedID 37946237
View details for PubMedCentralID PMC10633935
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What Factors Are Associated With Arterial Line-Related Limb Ischemia in Patients on Extracorporeal Membrane Oxygenation? A Single- Center Retrospective Cohort Study
JOURNAL OF CARDIOTHORACIC AND VASCULAR ANESTHESIA
2023; 37 (12): 2489-2498
Abstract
The primary purpose of this study was to identify factors associated with the development of arterial line-related limb ischemia in patients on extracorporeal membrane oxygenation (ECMO). The authors also sought to characterize and report the outcomes of patients who developed arterial line-related limb ischemia.Retrospective cohort study.A single academic tertiary referral ECMO center.Consecutive patients who were treated with ECMO over 6 years.Use of arterial line.A total of 278 consecutive ECMO patients were included, with 19 (7%) patients developing arterial line-related limb ischemia during the ECMO run. Postcannulation Sequential Organ Failure Assessment (SOFA) (adjusted odds ratio [aOR] 1.20, 95% CI 1.08-1.32), Acute Physiology and Chronic Health Evaluation-II (aOR 0.84, 95% CI 0.74-0.95), and adjusted Vasopressor Dose Equivalence (aOR 1.03, 95% CI 1.01-1.05) scores were independently associated with the development of arterial line-associated limb ischemia. A SOFA score of ≥17 at the time of ECMO cannulation had an 80% sensitivity and 87% specificity for predicting arterial line-related limb ischemia.Arterial line-related limb ischemia is much more common in ECMO patients than in the typical intensive care unit setting. The SOFA score may be useful in identifying which patients may be at risk for arterial line-related limb ischemia. As this was a single-center retrospective study, these results are inherently exploratory, and prospective multicenter studies are necessary to validate these results.
View details for DOI 10.1053/j.jvca.2023.08.131
View details for Web of Science ID 001109714500001
View details for PubMedID 37735020
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Impact of intraoperative blood products, fluid administration, and persistent hypothermia on bleeding leading to reexploration after cardiac surgery.
The Journal of thoracic and cardiovascular surgery
2023
Abstract
OBJECTIVE: Risk factors for severe postoperative bleeding after cardiac surgery remain multiple and incompletely elucidated. We evaluated the impact of intraoperative blood product transfusions, intravenous fluid administration, and persistently low core body temperature (CBT) at intensive care unit arrival on risk of perioperative bleeding leading to reexploration.METHODS: We retrospectively queried our tertiary care center's Society of Thoracic Surgeons Institutional Database for all index, on-pump, adult cardiac surgery patients between July 2016 and September 2022. Intraoperative fluid (crystalloid and colloid) and blood product administrations, as well as perioperative CBT data, were harvested from electronic medical records. Linear and nonlinear mixed models, treating surgeon as a random effect to account for inter-surgeon practice differences, were used to assess the association between above factors and reexploration for bleeding.RESULTS: Of 4037 patients, 151 (3.7%) underwent reexploration for bleeding. Reexplored patients experienced remarkably greater postoperative morbidity (23% vs 6%, P<.001) and 30-day mortality (14% vs 2%, P<.001). In linear models, progressively increasing IV crystalloid administration (adjusted odds ratio, 1.11, 95% confidence interval, 1.03-1.19) and decreasing CBT on intensive care unit arrival (adjusted odds ratio, 1.20; 95% confidence interval, 1.05-1.37) were associated with greater risk of bleeding leading to reexploration. Nonlinear analysis revealed increasing risk after 6L of crystalloid administration and a U-shaped relationship between CBT and reexploration risk. Intraoperative blood product transfusion of any kind was not associated with reexploration.CONCLUSIONS: We found evidence of both dilution- and hypothermia-related effects associated with perioperative bleeding leading to reexploration in cardiac surgery. Interventions targeting modification of such risk factors may decrease the rate this complication.
View details for DOI 10.1016/j.jtcvs.2023.10.011
View details for PubMedID 37839660
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Weekend Discharge Is Not Associated With Increased Readmission After Hyperthermic Intraperitoneal Chemotherapy
JOURNAL OF SURGICAL RESEARCH
2024; 293: 403-412
Abstract
We explored the association between weekend discharge and 30- and 90-d readmission rates in patients undergoing hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) for peritoneal carcinomatosis.The US HIPEC Collaborative database, comprised of a longitudinal cohort of patients undergoing CRS/HIPEC for peritoneal carcinomatosis at twelve academic institutions between 2000 and 2017, was queried for date of discharge information. Patients were retrospectively divided into weekday and weekend/holiday discharge groups. Patients <18 y old, lacking day of discharge information, or who experienced intraoperative/in-hospital mortality were excluded. Comparisons were made between patients discharged on a weekday versus those discharged on a weekend or major holiday.1415 patients met inclusion criteria for the study: 1108 (78%) patients with a weekday discharge and 308 (22%) with a weekend/holiday discharge. Median age at time of surgery was 55 y (Interquartile Range: 46-63); 59% (n = 841) patients were female, 25% (n = 328) of patients had high volume disease (defined as a peritoneal cancer index >20 intraoperatively), and 92% (n = 1210) of patients had a complete cytoreduction (defined as a completeness of cytoreduction score of 0 or 1). Overall, 15% (n = 218) of patients were readmitted within 30 d and 19% (n = 265) within 90 d. In a linear mixed effects model, weekend discharge was not associated with higher 30- or 90-d readmissions (P = 0.291, P = 0.743).Weekend discharges are safe following CRS/HIPEC. Length of stay initiatives should focus on discharging the patient when medically ready, rather than avoiding weekend discharge out of an abundance of caution.
View details for DOI 10.1016/j.jss.2023.08.026
View details for Web of Science ID 001094768200001
View details for PubMedID 37806228
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Risk Factors for Nondiagnostic Imaging in a Real-World Deployment of Artificial Intelligence Diabetic Retinal Examinations in an Integrated Health care System: Maximizing Workflow Efficiency Through Predictive Dilation
JOURNAL OF DIABETES SCIENCE AND TECHNOLOGY
2023: 302-308
Abstract
In the pivotal clinical trial that led to Food and Drug Administration De Novo "approval" of the first fully autonomous artificial intelligence (AI) diabetic retinal disease diagnostic system, a reflexive dilation protocol was used. Using real-world deployment data before implementation of reflexive dilation, we identified factors associated with nondiagnostic results. These factors allow a novel predictive dilation workflow, where patients most likely to benefit from pharmacologic dilation are dilated a priori to maximize efficiency and patient satisfaction.Retrospective review of patients who were assessed with autonomous AI at Johns Hopkins Medicine (8/2020 to 5/2021). We constructed a multivariable logistic regression model for nondiagnostic results to compare characteristics of patients with and without diagnostic results, using adjusted odds ratio (aOR). P < .05 was considered statistically significant.Of 241 patients (59% female; median age = 59), 123 (51%) had nondiagnostic results. In multivariable analysis, type 1 diabetes (T1D, aOR = 5.82, 95% confidence interval [CI]: 1.45-23.40, P = .01), smoking (aOR = 2.86, 95% CI: 1.36-5.99, P = .005), and age (every 10-year increase, aOR = 2.12, 95% CI: 1.62-2.77, P < .001) were associated with nondiagnostic results. Following feature elimination, a predictive model was created using T1D, smoking, age, race, sex, and hypertension as inputs. The model showed an area under the receiver-operator characteristics curve of 0.76 in five-fold cross-validation.We used factors associated with nondiagnostic results to design a novel, predictive dilation workflow, where patients most likely to benefit from pharmacologic dilation are dilated a priori. This new workflow has the potential to be more efficient than reflexive dilation, thus maximizing the number of at-risk patients receiving their diabetic retinal examinations.
View details for DOI 10.1177/19322968231201654
View details for Web of Science ID 001193603900001
View details for PubMedID 37798955
View details for PubMedCentralID PMC10973867
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Is Fasciotomy Associated With Increased Mortality in Extracorporeal Cardiopulmonary Resuscitation?
ASAIO JOURNAL
2023; 69 (8): 795-801
Abstract
Our primary objective was to identify if fasciotomy was associated with increased mortality in patients who developed acute compartment syndrome (ACS) on extracorporeal cardiopulmonary resuscitation (ECPR). Additionally, we sought to identify any additional risk factors for mortality in these patients and report the amputation-free survival following fasciotomy. We retrospectively reviewed adult ECPR patients from the Extracorporeal Life Support Organization registry who were diagnosed with ACS between 2013 and 2021. Of 764 ECPR patients with limb complications, 127 patients (17%) with ACS were identified, of which 78 (63%) had fasciotomies, and 14 (11%) had amputations. Fasciotomy was associated with a 23% rate of amputation-free survival. There were no significant differences in demographics or baseline laboratory values between those with and without fasciotomy. Overall, 88 of 127 (69%) patients with ACS died. With or without fasciotomy, the mortality of ACS patients was similar, 68% vs. 71%. Multivariable logistic regression demonstrated that body mass index (BMI; adjusted odds ratio [aOR] = 1.22, 95% confidence interval [CI] = 1.01-1.48) and 24 hour mean blood pressure (BP; aOR = 0.93, 95% CI = 0.88-0.99) were independently associated with mortality. Fasciotomy was not an independent risk factor for mortality (aOR = 0.24, 95% CI = 0.03-1.88). The results of this study may help guide surgical decision-making for patients who develop ACS after ECPR. However, the retrospective nature of this study does not preclude selection bias in patients who have received fasciotomy. Thus, prospective studies are necessary to confirm these findings.
View details for DOI 10.1097/MAT.0000000000001969
View details for Web of Science ID 001041500100021
View details for PubMedID 37171978
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Racial and ethnical discrepancy in hypoxemia detection in patients on extracorporeal membrane oxygenation
JTCVS OPEN
2023; 14: 145-170
Abstract
To determine whether there is racial/ethnical discrepancy between pulse oximetry (SpO2) and oxygen saturation (SaO2) in patients receiving extracorporeal membrane oxygenation (ECMO).This was a retrospective observational study at a tertiary academic ECMO center with adults (>18 years) on venoarterial (VA) or venovenous (VV) ECMO. Datapoints were excluded if oxygen saturation ≤70% or SpO2-SaO2 pairs were not measured within 10 minutes. The primary outcome was the presence of a SpO2-SaO2 discrepancy between different races/ethnicities. Bland-Altman analyses and linear mixed-effects modeling, adjusting for prespecified covariates, were used to assess the SpO2-SaO2 discrepancy between races/ethnicities. Occult hypoxemia was defined as SaO2 <88% with a time-matched SpO2 ≥92%.Of 139 patients receiving VA-ECMO and 57 patients receiving VV-ECMO, we examined 16,252 SpO2-SaO2 pairs. The SpO2-SaO2 discrepancy was greater in VV-ECMO (1.4%) versus VA-ECMO (0.15%). In VA-ECMO, SpO2 overestimated SaO2 in Asian (0.2%), Black (0.94%), and Hispanic (0.03%) patients and underestimated SaO2 in White (-0.06%) and nonspecified race (-0.80%) patients. The proportion of SpO2-SaO2 measurements considered occult hypoxemia was 70% from Black compared to 27% from White patients (P < .0001). In VV-ECMO, SpO2 overestimated SaO2 in Asian (1.0%), Black (2.9%), Hispanic (1.1%), and White (0.50%) patients and underestimated SaO2 in nonspecified race patients (-0.53%). In linear mixed-effects modeling, SpO2 overestimated SaO2 by 0.19% in Black patients (95% confidence interval, 0.045%-0.33%, P = .023). The proportion of SpO2-SaO2 measurements considered occult hypoxemia was 66% from Black compared with 16% from White patients (P < .0001).SpO2 overestimates SaO2 in Asian, Black, and Hispanic versus White patients, and this discrepancy was greater in VV-ECMO versus VA-ECMO, suggesting the need for physiological studies.
View details for DOI 10.1016/j.xjon.2023.02.011
View details for Web of Science ID 001318949000016
View details for PubMedID 37425474
View details for PubMedCentralID PMC10328809
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Understanding barriers to medical appointment keeping: A case-control study of predictive factors for no-shows and same-day cancellations in dermatology clinics in an academic medical center in the United States
JAAD INTERNATIONAL
2023; 11: 189-192
View details for DOI 10.1016/j.jdin.2023.03.002
View details for Web of Science ID 001226415100002
View details for PubMedID 37138826
View details for PubMedCentralID PMC10149410
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Prophylactic Hysterectomy During Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for High Grade Tumors is Associated with Fewer Pelvic Recurrences
ANNALS OF SURGICAL ONCOLOGY
2023: 4576-4578
View details for DOI 10.1245/s10434-023-13608-y
View details for Web of Science ID 000999664500005
View details for PubMedID 37249721
View details for PubMedCentralID PMC10426766
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Characteristics of delirium and its association with sedation and in-hospital mortality in patients with COVID-19 on veno-venous extracorporeal membrane oxygenation
FRONTIERS IN MEDICINE
2023; 10: 1172063
Abstract
Veno-venous extracorporeal membrane oxygenation (VV-ECMO) has been used in patients with COVID-19 acute respiratory distress syndrome (ARDS). We aim to assess the characteristics of delirium and describe its association with sedation and in-hospital mortality.We retrospectively reviewed adult patients on VV-ECMO for severe COVID-19 ARDS in the Johns Hopkins Hospital ECMO registry in 2020-2021. Delirium was assessed by the Confusion Assessment Method for the ICU (CAM-ICU) when patients scored-3 or above on the Richmond Agitation-Sedation Scale (RASS). Primary outcomes were delirium prevalence and duration in the proportion of days on VV-ECMO.Of 47 patients (median age = 51), 6 were in a persistent coma and 40 of the remaining 41 patients (98%) had ICU delirium. Delirium in the survivors (n = 21) and non-survivors (n = 26) was first detected at a similar time point (VV-ECMO day 9.5(5,14) vs. 8.5(5,21), p = 0.56) with similar total delirium days on VV-ECMO (9.5[3.3, 16.8] vs. 9.0[4.3, 28.3] days, p = 0.43). Non-survivors had numerically lower RASS scores on VV-ECMO days (-3.72[-4.42, -2.96] vs. -3.10[-3.91, -2.21], p = 0.06) and significantly prolonged delirium-unassessable days on VV-ECMO with a RASS of -4/-5 (23.0[16.3, 38.3] vs. 17.0(6,23), p = 0.03), and total VV-ECMO days (44.5[20.5, 74.3] vs. 27.0[21, 38], p = 0.04). The proportion of delirium-present days correlated with RASS (r = 0.64, p < 0.001), the proportions of days on VV-ECMO with a neuromuscular blocker (r = -0.59, p = 0.001), and with delirium-unassessable exams (r = -0.69, p < 0.001) but not with overall ECMO duration (r = 0.01, p = 0.96). The average daily dosage of delirium-related medications on ECMO days did not differ significantly. On an exploratory multivariable logistic regression, the proportion of delirium days was not associated with mortality.Longer duration of delirium was associated with lighter sedation and shorter paralysis, but it did not discern in-hospital mortality. Future studies should evaluate analgosedation and paralytic strategies to optimize delirium, sedation level, and outcomes.
View details for DOI 10.3389/fmed.2023.1172063
View details for Web of Science ID 001002535900001
View details for PubMedID 37305142
View details for PubMedCentralID PMC10248255
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Management of Postoperative Bleeding in Cardiac Surgery Begins in the OR
ANNALS OF THORACIC SURGERY
2023; 115 (6): 1557-1558
View details for DOI 10.1016/j.athoracsur.2022.10.004
View details for Web of Science ID 001003843100001
View details for PubMedID 36252722
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Highly multiplexed immune profiling throughout adulthood reveals kinetics of lymphocyte infiltration in the aging mouse prostate
AGING-US
2023; 15 (9): 3356-3380
Abstract
Aging is a significant risk factor for disease in several tissues, including the prostate. Defining the kinetics of age-related changes in these tissues is critical for identifying regulators of aging and evaluating interventions to slow the aging process and reduce disease risk. An altered immune microenvironment is characteristic of prostatic aging in mice, but whether features of aging in the prostate emerge predominantly in old age or earlier in adulthood has not previously been established. Using highly multiplexed immune profiling and time-course analysis, we tracked the abundance of 29 immune cell clusters in the aging mouse prostate. Early in adulthood, myeloid cells comprise the vast majority of immune cells in the 3-month-old mouse prostate. Between 6 and 12 months of age, there is a profound shift towards a T and B lymphocyte-dominant mouse prostate immune microenvironment. Comparing the prostate to other urogenital tissues, we found similar features of age-related inflammation in the mouse bladder but not the kidney. In summary, our study offers new insight into the kinetics of prostatic inflammaging and the window when interventions to slow down age-related changes may be most effective.
View details for Web of Science ID 000996587500011
View details for PubMedID 37179121
View details for PubMedCentralID PMC10449296
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Early United States experience with lung donation after circulatory death using thoracoabdominal normothermic regional perfusion
JOURNAL OF HEART AND LUNG TRANSPLANTATION
2023; 42 (6): 693-696
Abstract
Thoracoabdominal normothermic regional perfusion (TA-NRP) has recently begun being utilized in the United States for recovery of cardiothoracic allografts from some donors after circulatory death (DCD), but data on lungs recovered in this method is limited to case reports. We conducted a national retrospective review of lung transplants from DCD donors recovered using TA-NRP. Of the 434 total DCD lung transplants performed between January 2020 and March 2022, 17 were recovered using TA-NRP. Compared to direct recovery DCD transplants, recipients of TA-NRP DCD transplants had lower likelihood of ventilation >48 hours (23.5% vs 51.3%, p = 0.027) and similar likelihood of predischarge acute rejection, requirement for extracorporeal membrane oxygenation at 72 hours, hospital lengths of stay, and survival at 30, 60, and 90 days post-transplant. These early data suggest that DCD lung recovery using TA-NRP might be a safe way to further expand the donor pool and warrant further study.
View details for DOI 10.1016/j.healun.2023.03.001
View details for Web of Science ID 001002265200001
View details for PubMedID 36990867
View details for PubMedCentralID PMC10192114
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Neuromonitoring detects brain injury in patients receiving extracorporeal membrane oxygenation support
JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY
2023; 165 (6): 2104-+
Abstract
There is limited evidence on standardized protocols for optimal neurological monitoring methods in patients receiving extracorporeal membrane oxygenation (ECMO). We previously introduced protocolized noninvasive multimodal neuromonitoring using serial neurological examinations, electroencephalography, transcranial Doppler ultrasound, and somatosensory evoked potentials. The purpose of this study was to examine if standardized neuromonitoring is associated with detection of acute brain injury (ABI) and improved patient outcomes.A retrospective analysis of ECMO patients who received neurocritical care consultation was performed and outcomes were reviewed. The cohort was stratified according to those who did not receive standardized neuromonitoring (era 1: 2016-2017) and those who received standardized neuromonitoring (era 2: 2017-2020). Multivariable logistic regression was used to evaluate the association between standardized neuromonitoring and ABI.A total of 215 patients (mean age, 54 years; 60% male) underwent ECMO (71% venoarterial-ECMO) in our institution, 70 in era 1 and 145 in era 2. The proportion of patients diagnosed with ABI were 23% in era 1 and 33% in era 2 (P = .12). In multivariable logistic regression, standardized neuromonitoring (odds ratio, 2.24; 95% CI, 1.12-4.48; P = .02) and pre-ECMO cardiac arrest (odds ratio, 2.17; 95% CI, 1.14-4.14; P = .02) were independently associated with ABI. There was a greater proportion of patients with good neurological outcomes when discharged alive in era 2 (54% vs 30%; P = .04).Standardized neuromonitoring was associated with increased ABIs in ECMO patients. Although neuromonitoring does not prevent ABI from occurring, it might prevent worsening with timely interventions (eg, anticoagulation management, optimizing oxygen delivery and blood pressure), leading to improved neurological outcomes at discharge.
View details for DOI 10.1016/j.jtcvs.2021.09.063
View details for Web of Science ID 001009121200001
View details for PubMedID 34865837
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Sex differences in computed tomography angiography-derived coronary plaque burden in relation to invasive fractional flow reserve
JOURNAL OF CARDIOVASCULAR COMPUTED TOMOGRAPHY
2023; 17 (2): 112-119
Abstract
Distinct sex-related differences exist in coronary artery plaque burden and distribution. We aimed to explore sex differences in quantitative plaque burden by coronary CT angiography (CCTA) in relation to ischemia by invasive fractional flow reserve (FFR).This post-hoc analysis of the PACIFIC trial included 581 vessels in 203 patients (mean age 58.1 ± 8.7 years, 63.5% male) who underwent CCTA and per-vessel invasive FFR. Quantitative assessment of total, calcified, non-calcified, and low-density non-calcified plaque burden were performed using semiautomated software. Significant ischemia was defined as invasive FFR ≤0.8.The per-vessel frequency of ischemia was higher in men than women (33.5% vs. 7.5%, p < 0.001). Women had a smaller burden of all plaque subtypes (all p < 0.01). There was no sex difference on total, calcified, or non-calcified plaque burdens in vessels with ischemia; only low-density non-calcified plaque burden was significantly lower in women (beta: -0.183, p = 0.035). The burdens of all plaque subtypes were independently associated with ischemia in both men and women (For total plaque burden (5% increase): Men, OR: 1.15, 95%CI: 1.06-1.24, p = 0.001; Women, OR: 1.96, 95%CI: 1.11-3.46, p = 0.02). No significant interaction existed between sex and total plaque burden for predicting ischemia (interaction p = 0.108). The addition of quantitative plaque burdens to stenosis severity and adverse plaque characteristics improved the discrimination of ischemia in both men and women.In symptomatic patients with suspected CAD, women have a lower CCTA-derived burden of all plaque subtypes compared to men. Quantitative plaque burden provides independent and incremental predictive value for ischemia, irrespective of sex.
View details for DOI 10.1016/j.jcct.2022.12.002
View details for Web of Science ID 000989170100001
View details for PubMedID 36670043
View details for PubMedCentralID PMC10148895
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Lower Oxygen Tension and Intracranial Hemorrhage in Veno-venous Extracorporeal Membrane Oxygenation
LUNG
2023; 201 (3): 315-320
Abstract
We examined the relationship between 24-h pre- and post-cannulation arterial oxygen tension (PaO2) and arterial carbon dioxide tension (PaCO2) and subsequent acute brain injury (ABI) in patients receiving veno-venous extracorporeal membrane oxygenation (VV-ECMO) with granular arterial blood gas (ABG) data and institutional standardized neuromonitoring.Eighty-nine patients underwent VV-ECMO (median age = 50, 63% male). Twenty (22%) patients experienced ABI; intracranial hemorrhage (ICH) was the most common diagnosis (n = 14, 16%). Lower post-cannulation PaO2 levels were significantly associated with ICH (66 vs. 81 mmHg, p = 0.007) and a post-cannulation PaO2 level < 70 mmHg was more frequent in these patients (71% vs. 33%, p = 0.007). PaCO2 parameters were not associated with ABI. By multivariable logistic regression, hypoxemia post-cannulation increased the odds of ICH (OR = 5.06, 95% CI:1.41-18.17; p = 0.01).In summary, lower oxygen tension in the 24-h post-cannulation was associated with ICH development. The precise roles of peri-cannulation ABG changes deserve further investigation, as they may influence the management of VV-ECMO patients.
View details for DOI 10.1007/s00408-023-00618-6
View details for Web of Science ID 000974442300001
View details for PubMedID 37086285
View details for PubMedCentralID PMC10578342
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National Trends, Risk Factors, and Outcomes of Acute In-hospital Stroke After Lung Transplantation in the United States: Analysis of the United Network for Organ Sharing Registry.
Chest
2023
Abstract
BACKGROUND: Lung transplantation is the definitive treatment for end-stage lung failure. However, there have been no large, long-term studies on the impact of acute in-hospital stroke in this population.RESEARCH QUESTION: What are the trends, risk factors, and outcomes of acute stroke in patients undergoing lung transplantation in the United States?STUDY DESIGN AND METHODS: We identified adult first-time, isolated lung transplant (LTx) recipients from the United Network for Organ Sharing (UNOS) database, which comprehensively captures every transplant in the United States, between 5/2005 and 12/2020. Stroke was defined as occurring at any time after LTx but prior to discharge. Multivariable logistic regression with stepwise feature elimination was used to identify risk factors for stroke. Freedom from death in stroke vs. non-stroke patients was evaluated with Kaplan-Meier analysis. Cox proportional hazards analysis was used to identify predictors of death at 24 months.RESULTS: Of 28,564 patients (median age=60, 60% male), 653 (2.3%) experienced an acute in-hospital stroke after LTx. Median follow-up was 1.2 (stroke) and 3.0 years (non-stroke). Annual incidence of stroke increased (1.5% in 2005 to 2.4% in 2020, p-trend=0.007), as did lung allocation score (LAS) and utilization of post-LTx extracorporeal membrane oxygenation (postLTX-ECMO) (p=0.01 and p<0.001, respectively). Compared to those without, patients with stroke had lower survival at 1-month (84% vs. 98%), 12-months (61% vs. 88%), and 24 months (52% vs. 80%, p (log-rank) <0.001 for all). In Cox analysis, acute stroke conferred a high hazard of mortality (HR=3.01, 95%CI=2.67-3.41). PostLTx-ECMO was the strongest risk factor for stroke (adjusted odds ratio=2.98, 95%CI=2.19-4.06).INTERPRETATION: Acute in-hospital stroke following lung transplantation has been increasing over time and is associated with markedly worse short- and long-term survival. As increasingly sicker patients receive lung transplantation as well as stroke, further research on stroke characteristics, prevention, and management strategies is warranted.
View details for DOI 10.1016/j.chest.2023.04.007
View details for PubMedID 37054775
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Arterial oxygen and carbon dioxide tension and acute brain injury in extracorporeal cardiopulmonary resuscitation patients: Analysis of the extracorporeal life support organization registry
JOURNAL OF HEART AND LUNG TRANSPLANTATION
2023; 42 (4): 503-511
Abstract
Acute brain injury (ABI) remains common after extracorporeal cardiopulmonary resuscitation (ECPR). Using a large international multicenter cohort, we investigated the impact of peri-cannulation arterial oxygen (PaO2) and carbon dioxide (PaCO2) on ABI occurrence.We retrospectively analyzed adult (≥18 years old) ECPR patients in the Extracorporeal Life Support Organization registry from 1/2009 through 12/2020. Composite ABI included ischemic stroke, intracranial hemorrhage (ICH), seizures, and brain death. The registry collects 2 blood gas data pre- (6 hours) and post- (24 hours) cannulation. Blood gas parameters were classified as: hypoxia (<60mm Hg), normoxia (60-119mm Hg), and mild (120-199mm Hg), moderate (200-299mm Hg), and severe hyperoxia (≥300mm Hg); hypocarbia (<35mm Hg), normocarbia (35-44mm Hg), mild (45-54mm Hg) and severe hypercarbia (≥55mm Hg). Missing values were handled using multiple imputation. Multivariable logistic regression analysis was used to assess the relationship of PaO2 and PaCO2 with ABI.Of 3,125 patients with ECPR intervention (median age=58, 69% male), 488 (16%) experienced ABI (7% ischemic stroke; 3% ICH). In multivariable analysis, on-ECMO moderate (aOR=1.42, 95%CI: 1.02-1.97) and severe hyperoxia (aOR=1.59, 95%CI: 1.20-2.10) were associated with composite ABI. Additionally, severe hyperoxia was associated with ischemic stroke (aOR=1.63, 95%CI: 1.11-2.40), ICH (aOR=1.92, 95%CI: 1.08-3.40), and in-hospital mortality (aOR=1.58, 95%CI: 1.21-2.06). Mild hypercarbia pre-ECMO was protective of composite ABI (aOR=0.61, 95%CI: 0.44-0.84) and ischemic stroke (aOR=0.56, 95%CI: 0.35-0.89).Early severe hyperoxia (≥300mm Hg) on ECMO was a significant risk factor for ABI and mortality. Careful consideration should be given in early oxygen delivery in ECPR patients who are at risk of reperfusion injury.
View details for DOI 10.1016/j.healun.2022.10.019
View details for Web of Science ID 000966060000001
View details for PubMedID 36435686
View details for PubMedCentralID PMC10050131
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Costs and Readmissions Associated with Type A Aortic Dissections at High- and Low-Volume Centers
HEART SURGERY FORUM
2023; 26 (6): E694-E704
Abstract
Costs and readmissions associated with type A aortic dissection repairs are not well understood. We investigated statewide readmissions, costs, and outcomes associated with the surgical management of type A aortic dissection repairs at low- and high-volume centers.We identified all adult type A aortic dissection patients who underwent operative repair in the Maryland Health Services Cost Review Commission's database (2012-2020). Hospitals were stratified into high- (top quartile of total repairs) or low-volume centers.Of the 249 patients included, 193 (77.5%) were treated at a high-volume center. Patients treated at high- and low-volume centers had no differences in age, sex, race, primary payer, or severity (all p > 0.5). High- compared to low-volume centers had a greater proportion of patients transferred in (71.5% vs. 17.9%, p < 0.001). High-volume centers also had longer lengths of stay (12 vs. 8 days, p < 0.001), similar inpatient mortality (13.0% vs. 16.1%, p = 0.6), and similar proportion of patients readmitted (54.9% vs. 51.8%, p = 0.7). High-volume centers had greater index admission costs ($114,859 vs. $72,090, p < 0.001) and similar readmission costs ($48,367 vs. $42,204, p = 0.5). At high-volume centers, transferred patients compared to direct admissions had greater severity of illness (p = 0.05), similar mortality (p = 0.53), and greater lengths of stay (p = 0.05).High-volume centers had a greater number of patients transferred from other institutions compared to low-volume centers. High-volume centers were associated with increased index admission resource utilization, with transfer patients having higher illness severity and greater resource utilization, yet similar mortality, compared to direct admission patients.
View details for DOI 10.59958/hsf.6821
View details for Web of Science ID 001167625100003
View details for PubMedID 38178348
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Early Reexploration for Bleeding Is Associated With Improved Outcome in Cardiac Surgery
ANNALS OF THORACIC SURGERY
2023; 115 (1): 232-239
Abstract
Reexploration after cardiac surgery, most frequently for bleeding, is a quality metric used to assess surgical performance. This may cause surgeons to delay return to the operating room in favor of attempting nonoperative management. This study investigated the impact of the timing of reexploration on morbidity and mortality.This study was a single-institution retrospective review of all adult cardiac surgery patients from July 2010 to June 2020. Time to reexploration was assessed, and outcomes were compared across increasing time intervals. Reported bleeding sites were classified into 5 groups, and bleeding rate (chest tube output) was compared across bleeding sites. Univariable analysis was performed using the Fisher exact and Kruskal-Wallis tests. Multivariable logistic regression models were used for risk-adjusted analyses.Of 10 070 eligible patients, 251 (2.5%) required reexploration for postoperative bleeding. The most common site of bleeding was "any suture line" (n = 70; 28%). Interestingly, in 30% of cases (n = 75) "no active bleeding" site was reported. The highest rate of bleeding (mL/h) was observed in the "any mediastinal structure" group (median, 450; interquartile range [IQR], 185, 8878), and the lowest rate was noted in the "no active bleeding" group (median, 151.2; IQR, 102, 270). Both morbidity rates (0-4 hours, 12.3% vs 25-48 hours, 37.5%; P = .001) and mortality rates (0-4 hours, 3.1% vs 25-48 hours, 43.8%; P = .001) escalated significantly with increasing time to reexploration.Delayed reexploration for bleeding after cardiac surgery is associated with increased risk for morbidity and mortality. Early surgical intervention, particularly within 4 hours, may improve outcomes. Implications from using reoperation as a performance metric may lead to unnecessary delay and patient harm.
View details for DOI 10.1016/j.athoracsur.2022.07.037
View details for Web of Science ID 000908689300001
View details for PubMedID 35952856
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Perivascular fat attenuation for predicting adverse cardiac events in stable patients undergoing invasive coronary angiography
JOURNAL OF CARDIOVASCULAR COMPUTED TOMOGRAPHY
2022; 16 (6): 483-490
Abstract
Inflammation surrounding the coronary arteries can be non-invasively assessed using pericoronary adipose tissue attenuation (PCAT). While PCAT holds promise for further risk stratification of patients with low coronary artery disease (CAD) prevalence, its value in higher risk populations remains unknown.CORE320 enrolled patients referred for invasive coronary angiography with known or suspected CAD. Coronary computed tomography angiography (CCTA) images were collected for 381 patients for whom clinical outcomes were assessed 5 years after enrollment. Using semi-automated image analysis software, PCAT was obtained and normalized for the right coronary (RCA), left anterior descending (LAD), and left circumflex arteries (LCx). The association between PCAT and major adverse cardiovascular events (MACE) during follow up was assessed using Cox regression models.Thirty-seven patients were excluded due to technical failure. For the remaining 344 patients, median age was 62 (interquartile range, 55-68) with 59% having ≥1 coronary artery stenosis of ≥50% by quantitative coronary angiography. Mean attenuation values for PCAT in RCA, LAD, and LCx were -74.9, -74.2, and -71.2, respectively. Hazard ratios and 95% confidence intervals (CI) for normalized PCAT in the RCA, LAD, and LCx for MACE were 0.96 (CI: 0.75-1.22, p = 0.71), 1.31 (95% CI: 0.96-1.78, p = 0.09), and 0.98 (95% CI: 0.78-1.22, p = 0.84), respectively. For death, stroke, or myocardial infarction only, hazard ratios were 0.68 (0.44-1.07), 0.85 (0.56-1.29), and 0.57 (0.41-0.80), respectively.In patients referred for invasive coronary angiography with suspected CAD, PCAT did not predict MACE during long term follow up. Further studies are needed to understand the relationship of PCAT with CAD risk.
View details for DOI 10.1016/j.jcct.2022.05.004
View details for Web of Science ID 000905079700004
View details for PubMedID 35680534
View details for PubMedCentralID PMC9684349
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Arterial Carbon Dioxide and Acute Brain Injury in Venoarterial Extracorporeal Membrane Oxygenation
ASAIO JOURNAL
2022; 68 (12): 1501-1507
Abstract
Acute brain injury (ABI) occurs frequently in patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO). We examined the association between peri-cannulation arterial carbon dioxide tension (PaCO 2 ) and ABI with granular blood gas data. We retrospectively analyzed adult patients who underwent VA-ECMO at a tertiary care center with standardized neuromonitoring. Pre- and post-cannulation PaCO 2 were defined as the mean of all PaCO 2 values in the 12 hours before and after cannulation, respectively. Peri-cannulation PaCO 2 drop (∆PaCO 2 ) equaled pre- minus post-cannulation PaCO 2 . ABI included intracranial hemorrhage (ICH), ischemic stroke, hypoxic-ischemic brain injury, cerebral edema, seizure, and brain death. Univariable logistic regression analysis was performed for the presence of ABI. Out of 129 VA-ECMO patients (median age = 60, 63% male), 43 (33%) patients experienced ABI. Patients had a median of 11 (interquartile range: 8-14) peri-cannulation PaCO 2 values. Comparing patients with and without ABI, pre-cannulation (39 vs. 42 mm Hg; p = 0.38) and post-cannulation (37 vs. 36 mm Hg; p = 0.82) PaCO 2 were not different. However, higher pre-cannulation PaCO 2 (odds ratio [OR] = 2.10; 95% confidence interval [CI] = 1.10-4.00; p = 0.02) and larger ∆PaCO 2 (OR = 2.69; 95% CI = 1.18-6.13; p = 0.02) were associated with ICH. In conclusion, in a cohort with granular arterial blood gas (ABG) data and a standardized neuromonitoring protocol, higher pre-cannulation PaCO 2 and larger ∆PaCO 2 were associated with increased prevalence of ICH.
View details for DOI 10.1097/MAT.0000000000001699
View details for Web of Science ID 000894502700019
View details for PubMedID 35671442
View details for PubMedCentralID PMC9477972
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Outcomes after heart transplantation in patients who have undergone a bridge-to-bridge strategy
JTCVS OPEN
2022; 12: 255-268
Abstract
We compared posttransplant outcomes between patients bridged from temporary mechanical circulatory support to durable left ventricular assist device before transplant (bridge-to-bridge [BTB] strategy) and patients bridged from temporary mechanical circulatory support directly to transplant (bridge-to-transplant [BTT] strategy).We identified adult heart transplant recipients in the Organ Procurement and Transplantation Network database between 2005 and 2020 who were supported with extracorporeal membrane oxygenation, intra-aortic balloon pump, or temporary ventricular assist device as a BTB or BTT strategy. Kaplan-Meier survival analysis and Cox regressions were used to assess 1-year, 5-year, and 10-year survival. Posttransplant length of stay and complications were compared as secondary outcomes.In total, 201 extracorporeal membrane oxygenation (61 BTB, 140 BTT), 1385 intra-aortic balloon pump (460 BTB, 925 BTT), and 234 temporary ventricular assist device (75 BTB, 159 BTT) patients were identified. For patients supported with extracorporeal membrane oxygenation, intra-aortic balloon pump, or temporary ventricular assist device, there were no differences in survival between BTB and BTT at 1 and 5 years posttransplant, as well as 10 years posttransplant even after adjusting for baseline characteristics. The extracorporeal membrane oxygenation BTB group had greater rates of acute rejection (32.8% vs 13.6%; P = .002) and lower rates of dialysis (1.6% vs 21.4%; P < .001). For intra-aortic balloon pump and temporary ventricular assist device patients, there were no differences in posttransplant length of stay, acute rejection, airway compromise, stroke, dialysis, or pacemaker insertion between BTB and BTT recipients.BTB patients have similar short- and midterm posttransplant survival as BTT patients. Future studies should continue to investigate the tradeoff between prolonged temporary mechanical circulatory support versus transitioning to durable mechanical circulatory support.
View details for DOI 10.1016/j.xjon.2022.08.011
View details for Web of Science ID 001318554000024
View details for PubMedID 36590736
View details for PubMedCentralID PMC9801290
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Trends, Outcomes, and Predictors of Acute In-hospital Stroke after Lung Transplantation: An Analysis of the United Network for Organ Sharing Database
LIPPINCOTT WILLIAMS & WILKINS. 2022: S265
View details for DOI 10.1097/01.XCS.0000895096.45527.53
View details for Web of Science ID 000867889300527
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Machine Learning From Quantitative Coronary Computed Tomography Angiography Predicts Fractional Flow Reserve-Defined Ischemia and Impaired Myocardial Blood Flow
CIRCULATION-CARDIOVASCULAR IMAGING
2022; 15 (10): e014369
Abstract
A pathophysiological interplay exists between plaque morphology and coronary physiology. Machine learning (ML) is increasingly being applied to coronary computed tomography angiography (CCTA) for cardiovascular risk stratification. We sought to assess the performance of a ML score integrating CCTA-based quantitative plaque features for predicting vessel-specific ischemia by invasive fractional flow reserve (FFR) and impaired myocardial blood flow (MBF) by positron emission tomography (PET).This post-hoc analysis of the PACIFIC trial (Prospective Comparison of Cardiac Positron Emission Tomography/Computed Tomography [CT]' Single Photon Emission Computed Tomography/CT Perfusion Imaging and CT Coronary Angiography with Invasive Coronary Angiography) included 208 patients with suspected coronary artery disease who prospectively underwent CCTA' [15O]H2O PET, and invasive FFR. Plaque quantification from CCTA was performed using semiautomated software. An ML algorithm trained on the prospective NXT trial (484 vessels) was used to develop a ML score for the prediction of ischemia (FFR≤0.80), which was then evaluated in 581 vessels from the PACIFIC trial. Thereafter, the ML score was applied for predicting impaired hyperemic MBF (≤2.30 mL/min per g) from corresponding PET scans. The performance of the ML score was compared with CCTA reads and noninvasive FFR derived from CCTA (FFRCT).One hundred thirty-nine (23.9%) vessels had FFR-defined ischemia, and 195 (33.6%) vessels had impaired hyperemic MBF. For the prediction of FFR-defined ischemia, the ML score yielded an area under the receiver-operating characteristic curve of 0.92, which was significantly higher than that of visual stenosis grade (0.84; P<0.001) and comparable with that of FFRCT (0.93; P=0.34). Quantitative percent diameter stenosis and low-density noncalcified plaque volume had the greatest ML feature importance for predicting FFR-defined ischemia. When applied for impaired MBF prediction, the ML score exhibited an area under the receiver-operating characteristic curve of 0.80; significantly higher than visual stenosis grade (area under the receiver-operating characteristic curve 0.74; P=0.02) and comparable with FFRCT (area under the receiver-operating characteristic curve 0.77; P=0.16).An externally validated ML score integrating CCTA-based quantitative plaque features accurately predicts FFR-defined ischemia and impaired MBF by PET, performing superiorly to standard CCTA stenosis evaluation and comparably to FFRCT.
View details for DOI 10.1161/CIRCIMAGING.122.014369
View details for Web of Science ID 000874384700001
View details for PubMedID 36252116
View details for PubMedCentralID PMC10085569
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Twelve-month observational study of children with cancer in 41 countries during the COVID-19 pandemic
BMJ GLOBAL HEALTH
2022; 7 (10)
Abstract
Childhood cancer is a leading cause of death. It is unclear whether the COVID-19 pandemic has impacted childhood cancer mortality. In this study, we aimed to establish all-cause mortality rates for childhood cancers during the COVID-19 pandemic and determine the factors associated with mortality.Prospective cohort study in 109 institutions in 41 countries.children <18 years who were newly diagnosed with or undergoing active treatment for acute lymphoblastic leukaemia, non-Hodgkin's lymphoma, Hodgkin lymphoma, retinoblastoma, Wilms tumour, glioma, osteosarcoma, Ewing sarcoma, rhabdomyosarcoma, medulloblastoma and neuroblastoma. Of 2327 cases, 2118 patients were included in the study. The primary outcome measure was all-cause mortality at 30 days, 90 days and 12 months.All-cause mortality was 3.4% (n=71/2084) at 30-day follow-up, 5.7% (n=113/1969) at 90-day follow-up and 13.0% (n=206/1581) at 12-month follow-up. The median time from diagnosis to multidisciplinary team (MDT) plan was longest in low-income countries (7 days, IQR 3-11). Multivariable analysis revealed several factors associated with 12-month mortality, including low-income (OR 6.99 (95% CI 2.49 to 19.68); p<0.001), lower middle income (OR 3.32 (95% CI 1.96 to 5.61); p<0.001) and upper middle income (OR 3.49 (95% CI 2.02 to 6.03); p<0.001) country status and chemotherapy (OR 0.55 (95% CI 0.36 to 0.86); p=0.008) and immunotherapy (OR 0.27 (95% CI 0.08 to 0.91); p=0.035) within 30 days from MDT plan. Multivariable analysis revealed laboratory-confirmed SARS-CoV-2 infection (OR 5.33 (95% CI 1.19 to 23.84); p=0.029) was associated with 30-day mortality.Children with cancer are more likely to die within 30 days if infected with SARS-CoV-2. However, timely treatment reduced odds of death. This report provides crucial information to balance the benefits of providing anticancer therapy against the risks of SARS-CoV-2 infection in children with cancer.
View details for DOI 10.1136/bmjgh-2022-008797
View details for Web of Science ID 000870714500006
View details for PubMedID 36261229
View details for PubMedCentralID PMC9581782
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Early Low Pulse Pressure in VA-ECMO Is Associated with Acute Brain Injury
NEUROCRITICAL CARE
2023; 38 (3): 612-621
Abstract
Pulse pressure is a dynamic marker of cardiovascular function and is often impaired in patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO). Pulsatile blood flow also serves as a regulator of vascular endothelium, and continuous-flow mechanical circulatory support can lead to endothelial dysfunction. We explored the impact of early low pulse pressure on occurrence of acute brain injury (ABI) in VA-ECMO.We conducted a retrospective analysis of adults with VA-ECMO at a tertiary care center between July 2016 and January 2021. Patients underwent standardized multimodal neuromonitoring throughout ECMO support. ABI included intracranial hemorrhage, ischemic stroke, hypoxic ischemic brain injury, cerebral edema, seizure, and brain death. Blood pressures were recorded every 15 min. Low pulse pressure was defined as a median pulse pressure < 20 mm Hg in the first 12 h of ECMO. Multivariable logistic regression was performed to investigate the association between pulse pressure and ABI.We analyzed 5138 blood pressure measurements from 123 (median age 63; 63% male) VA-ECMO patients (54% peripheral; 46% central cannulation), of whom 41 (33%) experienced ABI. Individual ABIs were as follows: ischemic stroke (n = 18, 15%), hypoxic ischemic brain injury (n = 14, 11%), seizure (n = 8, 7%), intracranial hemorrhage (n = 7, 6%), cerebral edema (n = 7, 6%), and brain death (n = 2, 2%). Fifty-eight (47%) patients had low pulse pressure. In a multivariable model adjusting for preselected covariates, including cannulation strategy (central vs. peripheral), lactate on ECMO day 1, and left ventricle venting strategy, low pulse pressure was independently associated with ABI (adjusted odds ratio 2.57, 95% confidence interval 1.05-6.24). In a model with the same covariates, every 10-mm Hg decrease in pulse pressure was associated with 31% increased odds of ABI (95% confidence interval 1.01-1.68). In a sensitivity analysis model adjusting for systolic pressure, pulse pressure remained significantly associated with ABI.Early low pulse pressure (< 20 mm Hg) was associated with ABI in VA-ECMO patients. Low pulse pressure may serve as a marker of ABI risk, which necessitates close neuromonitoring for early detection.
View details for DOI 10.1007/s12028-022-01607-y
View details for Web of Science ID 000860383600002
View details for PubMedID 36167950
View details for PubMedCentralID PMC10040467
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Pre-operative Machine Learning for Heart Transplant Patients Bridged with Temporary Mechanical Circulatory Support
JOURNAL OF CARDIOVASCULAR DEVELOPMENT AND DISEASE
2022; 9 (9)
Abstract
Background: Existing prediction models for post-transplant mortality in patients bridged to heart transplantation with temporary mechanical circulatory support (tMCS) perform poorly. A more reliable model would allow clinicians to provide better pre-operative risk assessment and develop more targeted therapies for high-risk patients. Methods: We identified adult patients in the United Network for Organ Sharing database undergoing isolated heart transplantation between 01/2009 and 12/2017 who were supported with tMCS at the time of transplant. We constructed a machine learning model using extreme gradient boosting (XGBoost) with a 70:30 train:test split to predict 1-year post-operative mortality. All pre-transplant variables available in the UNOS database were included to train the model. Shapley Additive Explanations was used to identify and interpret the most important features for XGBoost predictions. Results: A total of 1584 patients were included, with a median age of 56 (interquartile range: 46-62) and 74% male. Actual 1-year mortality was 12.1%. Out of 498 available variables, 43 were selected for the final model. The area under the receiver operator characteristics curve (AUC) for the XGBoost model was 0.71 (95% CI: 0.62-0.78). The most important variables predictive of 1-year mortality included recipient functional status, age, pulmonary capillary wedge pressure (PCWP), cardiac output, ECMO usage, and serum creatinine. Conclusions: An interpretable machine learning model trained on a large clinical database demonstrated good performance in predicting 1-year mortality for patients bridged to heart transplantation with tMCS. Machine learning may be used to enhance clinician judgement in the care of markedly high-risk transplant recipients.
View details for DOI 10.3390/jcdd9090311
View details for Web of Science ID 000856397100001
View details for PubMedID 36135456
View details for PubMedCentralID PMC9500687
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Temporary Mechanical Circulatory Support for Transcatheter Aortic Valve Replacement
JOURNAL OF SURGICAL RESEARCH
2022; 280: 363-370
Abstract
This study aimed to characterize the use of temporary mechanical circulatory support (tMCS) among patients undergoing transcatheter aortic valve replacement (TAVR) using a nationally representative database.The 2012-2018 National Inpatient Sample was queried for adult patients who underwent isolated TAVR. The tMCS group was comprised of those who required extracorporeal membrane oxygenation, percutaneous ventricular assist device, or intra-aortic balloon pump during index hospitalization. We evaluated temporal trends in the utilization of tMCS using Cuzick's test. Furthermore, a multivariable logistic regression was used to identify factors associated with tMCS use and its impact on in-hospital mortality, selected complications, and nonhome discharge.Of an estimated 215,925 patients who underwent TAVR, 3085 (1.4%) required tMCS during their hospital course. The most common modality of tMCS was intra-aortic balloon pump (49%), followed by extracorporeal membrane oxygenation (27%) then percutaneous ventricular assist device (18%). Seven percent of tMCS patients were supported by > 1 device. The annual incidence of tMCS usage decreased over the study period, from 3% in 2012 to 1% in 2018 (P-trend < 0.01). Nonelective admission, congestive heart failure, coagulopathy, and liver disease were strong independent predictors of requiring tMCS. Patients requiring tMCS had a 31.8% in-hospital mortality rate (adjusted odds ratio = 23, 95% confidence interval 18.5-28.5), longer length of stay (9 d versus 3, P < 0.001), and higher costs ($84,600 versus $48,100, P < 0.001) than those who did not.The use of tMCS during TAVR has decreased over time but remains associated with a 23-fold increased mortality rate and significant clinical and resource utilization burden.
View details for DOI 10.1016/j.jss.2022.07.034
View details for Web of Science ID 000864472000013
View details for PubMedID 36037613
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Massive left atrial thrombus evades multimodality imaging as a myxoma in a bicaval heart transplant recipient
JOURNAL OF CARDIAC SURGERY
2022; 37 (9): 2884-2887
Abstract
Intracardiac masses are an extremely rare and poorly described complication following a bicaval heart transplantation. We describe the case of an asymptomatic 62-year-old male with a large left atrial mass found incidentally on transthoracic echocardiography 6 years post-transplant. A battery of additional imaging tests was ordered including transesophageal echocardiography, 18 F-fluorodeoxyglucose positron emission tomography/computed tomography, and T1 and T2 magnetic resonance imaging. Although imaging biomarkers were generally nonspecific, the mass was most consistent with a cardiac myxoma. However, intraoperative findings confirmed by pathology revealed a massive organizing thrombus. The patient had an uneventful recovery after surgical removal of the mass. Our case highlights a very rare phenomenon in heart transplant recipients which remains a unique diagnostic challenge even with current advances in imaging.
View details for DOI 10.1111/jocs.16708
View details for Web of Science ID 000820620200001
View details for PubMedID 35789119
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Resting Energy Expenditure of Patients on Venovenous Extracorporeal Membrane Oxygenation for Adult Respiratory Distress Syndrome: A Pilot Study
CRITICAL CARE EXPLORATIONS
2022; 4 (7): e0730
Abstract
The objectives of this study were to 1) in patients without pulmonary function, determine resting energy expenditure (REE) in venovenous extracorporeal membrane oxygenation (ECMO) acute respiratory distress syndrome (ARDS) patients by paralysis status and 2) determine the threshold tidal volume (TV) associated with meaningful gas exchange as determined by measurable end-tidal carbon dioxide elimination (etV̇co2).Retrospective observational study.A tertiary high ECMO volume academic institution.Ten adult ARDS patients on venovenous ECMO.None.The modified Weir equation, Fick principle, Henderson-Hasselbalch equation, ECMO flow, hemoglobin, and pre and post oxygenator blood gases were used to determine ECMO carbon dioxide production (V̇co2), ECMO oxygen consumption, and REE. REE values were matched to patients' paralysis status based on medication flowsheets and compared using a paired t test. Linear regression was performed to determine the threshold TV normalized to ideal body weight (IBW) associated with measurable ventilator etV̇co2, above which meaningful ventilation occurs. When lungs were not functioning, patients had significantly lower mean REE when paralyzed (23.4 ± 2.8 kcal/kg/d) than when not paralyzed (29.2 ± 5.8 kcal/kg/d) (p = 0.02). Furthermore, mean REE was not similar between patients and varied as much as 1.7 times between patients when paralyzed and as much as 1.4 times when not paralyzed. Linear regression showed that ventilator V̇co2 was measurable and increased linearly when TV was greater than or equal to 0.7 mL/kg.REE is patient-specific and varies significantly with and without patient paralysis. When TV exceeds 0.7 mL/kg IBW, ventilator V̇co2 increases measurably and must be considered in determining total REE.
View details for DOI 10.1097/CCE.0000000000000730
View details for Web of Science ID 001275973000013
View details for PubMedID 35923588
View details for PubMedCentralID PMC9296180
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Caseous necrosis of the mitral annulus masquerading as an intracardiac mass.
Global cardiology science & practice
2022; 2022 (1-2): e202201
Abstract
Caseous necrosis of the mitral annulus is a rare condition which typically involves the posterior leaflet or annulus. We report the case of a 71-year-old female with extensive comorbidities, presenting with dyspnea and angina, who had an incidental echocardiographic finding of a mass on or near the mitral valve. The mass increased in size over the course of three years and was associated with severe mitral regurgitation. The mass was initially thought to be a myxoma, however, surgical exploration revealed caseous necrosis of the posterior mitral annulus. Following removal of the necrotic tissue and distorted mitral leaflet, a bioprosthetic mitral valve was implanted and the patient recovered uneventfully.
View details for DOI 10.21542/gcsp.2022.1
View details for PubMedID 36339670
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Relative contributions of sex hormones, sex chromosomes, and gonads to sex differences in tissue gene regulation
GENOME RESEARCH
2022; 32 (5): 807-824
Abstract
Sex differences in physiology and disease in mammals result from the effects of three classes of factors that are inherently unequal in males and females: reversible (activational) effects of gonadal hormones, permanent (organizational) effects of gonadal hormones, and cell-autonomous effects of sex chromosomes, as well as genes driven by these classes of factors. Often, these factors act together to cause sex differences in specific phenotypes, but the relative contribution of each and the interactions among them remain unclear. Here, we used the four core genotypes (FCG) mouse model with or without hormone replacement to distinguish the effects of each class of sex-biasing factors on transcriptome regulation in liver and adipose tissues. We found that the activational hormone levels have the strongest influence on gene expression, followed by the organizational gonadal sex effect, and last, sex chromosomal effect, along with interactions among the three factors. Tissue specificity was prominent, with a major impact of estradiol on adipose tissue gene regulation and of testosterone on the liver transcriptome. The networks affected by the three sex-biasing factors include development, immunity and metabolism, and tissue-specific regulators were identified for these networks. Furthermore, the genes affected by individual sex-biasing factors and interactions among factors are associated with human disease traits such as coronary artery disease, diabetes, and inflammatory bowel disease. Our study offers a tissue-specific account of the individual and interactive contributions of major sex-biasing factors to gene regulation that have broad impact on systemic metabolic, endocrine, and immune functions.
View details for DOI 10.1101/gr.275965.121
View details for Web of Science ID 000802837300001
View details for PubMedID 35396276
View details for PubMedCentralID PMC9104702
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Massive primary cardiac synovial sarcoma of the left atrium: a case report
JOURNAL OF CARDIOTHORACIC SURGERY
2022; 17 (1): 76
Abstract
Synovial sarcomas are tumors typically located in the extremities and characterized by a t(X;18)(p11.2;q11.2) chromosomal translocation. With only around 100 cases reported in the literature, cardiac synovial sarcomas are extremely rare.We describe a case of a 59-year-old male who presented to his primary care physician with chest pain, palpitations, and dyspnea and was diagnosed with atrial flutter. Following atrial ablation, a transthoracic echocardiogram incidentally revealed a 5.5 × 5.0 cm heterogeneous mass. Further workup found a heterogeneous mass with mild fluorodeoxyglucose uptake that was abutting the left atrium, left ventricle, and left pulmonary veins. The tumor was resected and confirmed to be a monophasic synovial sarcoma with a SS18-SSX gene fusion. Four months post-operative, the patient had recovered well from surgery. He is currently undergoing concurrent radiation and chemotherapy.Due to the rarity of this tumor, guidelines on diagnosis and treatment come only from case reports. Our case describes a primary cardiac synovial sarcoma arising from the left atrium in the atrioventricular groove in which diagnosis of atrial flutter preceded detection of the mass.
View details for DOI 10.1186/s13019-022-01822-w
View details for Web of Science ID 000782602500002
View details for PubMedID 35422025
View details for PubMedCentralID PMC9009006
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Impact of the COVID-19 pandemic on patients with paediatric cancer in low-income, middle-income and high-income countries: a multicentre, international, observational cohort study
BMJ OPEN
2022; 12 (4): e054690
Abstract
Paediatric cancer is a leading cause of death for children. Children in low-income and middle-income countries (LMICs) were four times more likely to die than children in high-income countries (HICs). This study aimed to test the hypothesis that the COVID-19 pandemic had affected the delivery of healthcare services worldwide, and exacerbated the disparity in paediatric cancer outcomes between LMICs and HICs.A multicentre, international, collaborative cohort study.91 hospitals and cancer centres in 39 countries providing cancer treatment to paediatric patients between March and December 2020.Patients were included if they were under the age of 18 years, and newly diagnosed with or undergoing active cancer treatment for Acute lymphoblastic leukaemia, non-Hodgkin's lymphoma, Hodgkin lymphoma, Wilms' tumour, sarcoma, retinoblastoma, gliomas, medulloblastomas or neuroblastomas, in keeping with the WHO Global Initiative for Childhood Cancer.All-cause mortality at 30 days and 90 days.1660 patients were recruited. 219 children had changes to their treatment due to the pandemic. Patients in LMICs were primarily affected (n=182/219, 83.1%). Relative to patients with paediatric cancer in HICs, patients with paediatric cancer in LMICs had 12.1 (95% CI 2.93 to 50.3) and 7.9 (95% CI 3.2 to 19.7) times the odds of death at 30 days and 90 days, respectively, after presentation during the COVID-19 pandemic (p<0.001). After adjusting for confounders, patients with paediatric cancer in LMICs had 15.6 (95% CI 3.7 to 65.8) times the odds of death at 30 days (p<0.001).The COVID-19 pandemic has affected paediatric oncology service provision. It has disproportionately affected patients in LMICs, highlighting and compounding existing disparities in healthcare systems globally that need addressing urgently. However, many patients with paediatric cancer continued to receive their normal standard of care. This speaks to the adaptability and resilience of healthcare systems and healthcare workers globally.
View details for DOI 10.1136/bmjopen-2021-054690
View details for Web of Science ID 000789493400010
View details for PubMedID 35410925
View details for PubMedCentralID PMC9021459
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Pulmonary artery transection for resection of a middle mediastinal paraganglioma
CLINICAL CASE REPORTS
2022; 10 (4): e05600
Abstract
We report the case of a 65-year-old male patient who presented with chest pain and was found to have a mediastinal paraganglioma between the left atrium and main pulmonary artery. This is the first reported case of a mediastinal paraganglioma resection utilization transection of the main pulmonary artery.
View details for DOI 10.1002/ccr3.5600
View details for Web of Science ID 000779382200001
View details for PubMedID 35425604
View details for PubMedCentralID PMC8991763
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Mild hypothermia and neurologic outcomes in patients undergoing venoarterial extracorporeal membrane oxygenation
JOURNAL OF CARDIAC SURGERY
2022; 37 (4): 825-830
Abstract
Patients with venoarterial extracorporeal membrane oxygenation (VA-ECMO) are at risk of cerebral reperfusion injury after prolonged hypoperfusion and immediate restoration of systemic blood flow. We aimed to examine the impact of mild hypothermia during the first 24 h post-ECMO on neurological outcomes in VA-ECMO patients.This was a retrospective study of adult VA-ECMO patients from a tertiary care center. Mild hypothermia was defined as 32-36°C during the first 24 h post-ECMO. The primary outcome was a good neurological function at discharge measured by a modified Rankin Scale ≤3. Multivariable logistic regression analysis was performed for primary outcome adjusting for pre-specified covariates.Overall, 128 consecutive patients with VA-ECMO support (median age: 60 years and 63% males) were included. Within the first 24 h of VA-ECMO cannulation, we found a median of 71 readings per patient (interquartile range 45-88). Eighty-eight patients (68.8%) experienced mild hypothermia within the first 24 h while 18 of those 88 patients (14.2%) had a mean temperature <36°C. ECMO indications included post-cardiotomy shock (39.8%), cardiac arrest (29.7%), and cardiogenic shock (26.6%). Duration of mild hypothermia, but not mean temperature, was independently associated with increased odds of good neurological outcome at discharge (odds ratio [OR] = 1.16, 95% confidence interval [CI] = 1.04-1.31, p = .01) after adjusting for age, the severity of illness, post-ECMO systemic hemorrhage, post-cardiotomy shock, acute brain injury, and mean 24-h PaO2 . Neither duration of mild hypothermia (OR = 0.93, CI = 0.84-1.03, p = .17) nor mean temperature (OR = 0.78, CI = 0.29-2.08, p = .62) was significantly associated with mortality. Similarly, duration of mild hypothermia (p = .47) and mean 24-h temperature (p = .76) were not significantly associated with the frequency of systemic hemorrhages.In this single-center study, a longer duration of mild hypothermia during the first 24 h of ECMO support was significantly associated with improved neurological outcomes. Mild hypothermia was not associated with an increased risk of systemic hemorrhage or improved survival.
View details for DOI 10.1111/jocs.16308
View details for Web of Science ID 000754393200001
View details for PubMedID 35152478
View details for PubMedCentralID PMC8891050
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Machine learning from quantitative coronary computed tomography angiography predicts ischemia and impaired myocardial blood flow
OXFORD UNIV PRESS. 2021: 206
View details for Web of Science ID 000720456900161
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Bridge to transplantation from mechanical circulatory support: a narrative review
JOURNAL OF THORACIC DISEASE
2021; 13 (12): 6911-6923
Abstract
To highlight recent developments in the utilization of mechanical circulatory support (MCS) devices as bridge-to-transplant strategies and to discuss trends in MCS use following the changes to the United Network for Organ Sharing (UNOS) heart allocation system.MCS devices have played an increasingly important role in the treatment of heart failure patients. Over the past several years, technological advancements have led to new developments in MCS devices and expanding indications for MCS use. In October of 2018, the UNOS heart allocation policy was revised to prioritize higher-urgency patients, including those supported with temporary MCS devices. Since then, changes in trends of MCS utilization have been observed.Articles from the PubMed database regarding the use of MCS devices as bridge-to-transplant strategies were reviewed.Over the past decade, utilization of temporary MCS devices, which include the intra-aortic balloon pump (IABP), percutaneous ventricular assist devices (pVADs), and extracorporeal membrane oxygenation (ECMO), has become increasingly common. Recent advancements in MCS include the development of pVADs that can fully unload the left ventricle (LV) as well as devices designed to provide right-sided support. Technological advancements in durable left ventricular assist devices (LVADs) have also led to improved outcomes both on the device and following heart transplantation. Following the 2018 UNOS heart allocation policy revision, the utilization of temporary MCS in advanced heart failure patients has further increased and the proportion of patients bridged directly from a temporary MCS device has exponentially risen. However, following the start of the COVID-19 pandemic, the trends have reversed, with a decrease in the percentage of patients bridged from a temporary MCS device. As long-term data following the allocation policy revision becomes available, future studies should investigate how trends in MCS use for patients with advanced heart failure continue to evolve.
View details for DOI 10.21037/jtd-21-832
View details for Web of Science ID 000719384600001
View details for PubMedID 35070375
View details for PubMedCentralID PMC8743412
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Systematic evaluation of transcriptomics-based deconvolution methods and references using thousands of clinical samples
BRIEFINGS IN BIOINFORMATICS
2021; 22 (6)
Abstract
Estimating cell type composition of blood and tissue samples is a biological challenge relevant in both laboratory studies and clinical care. In recent years, a number of computational tools have been developed to estimate cell type abundance using gene expression data. Although these tools use a variety of approaches, they all leverage expression profiles from purified cell types to evaluate the cell type composition within samples. In this study, we compare 12 cell type quantification tools and evaluate their performance while using each of 10 separate reference profiles. Specifically, we have run each tool on over 4000 samples with known cell type proportions, spanning both immune and stromal cell types. A total of 12 of these represent in vitro synthetic mixtures and 300 represent in silico synthetic mixtures prepared using single-cell data. A final 3728 clinical samples have been collected from the Framingham cohort, for which cell populations have been quantified using electrical impedance cell counting. When tools are applied to the Framingham dataset, the tool Estimating the Proportions of Immune and Cancer cells (EPIC) produces the highest correlation, whereas Gene Expression Deconvolution Interactive Tool (GEDIT) produces the lowest error. The best tool for other datasets is varied, but CIBERSORT and GEDIT most consistently produce accurate results. We find that optimal reference depends on the tool used, and report suggested references to be used with each tool. Most tools return results within minutes, but on large datasets runtimes for CIBERSORT can exceed hours or even days. We conclude that deconvolution methods are capable of returning high-quality results, but that proper reference selection is critical.
View details for DOI 10.1093/bib/bbab265
View details for Web of Science ID 000733325700135
View details for PubMedID 34346485
View details for PubMedCentralID PMC8768458
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MACHINE LEARNING ISCHEMIA RISK SCORE FROM CORONARY CT ANGIOGRAPHY PREDICTS LESION-SPECIFIC ISCHEMIA AND IMPAIRED MYOCARDIAL BLOOD FLOW: RESULTS FROM THE PACIFIC TRIAL
ELSEVIER SCIENCE INC. 2021: 1269
View details for Web of Science ID 000647487501277